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and trend data to 974 include, the following aggregate patient data: \(Needs to be defined.\) 975 )>>endobj712 0 obj<</Dest[68 0 R/XYZ 36 579 null]/Next 711 0 R/Parent 704 0 R/Prev 713 0 R/SE 681 0 R/Title( 972 )>>endobj713 0 obj<</Dest[68 0 R/XYZ 309 624 null]/Next 712 0 R/Parent 704 0 R/Prev 714 0 R/SE 680 0 R/Title(\(V\) The trauma multidisciplinary team shall participate 969 in the QAPI meetings and activities; the QAPI meetings shall be documented and include the 970 attendance, activities, actions, and follow-up. 971 )>>endobj714 0 obj<</Dest[68 0 R/XYZ 36 635 null]/Next 713 0 R/Parent 704 0 R/Prev 715 0 R/SE 679 0 R/Title( 968 )>>endobj715 0 obj<</Dest[68 0 R/XYZ 36 720 null]/Next 714 0 R/Parent 704 0 R/Prev 716 0 R/SE 677 0 R/Title(composed of the trauma medical director \(TMD\), the trauma program manager 962 \(TPM\), an executive officer of the facility, a trauma nurse active in the 963 management of trauma patients, a trauma nurse active in the management of 964 pediatric trauma \patients as applicable, and physicians and surgeons that provide 965 coverage or care to trauma patients, and other healthcare professionals 966 participating in the care of major or severe trauma patients. 967 )>>endobj716 0 obj<</Dest[66 0 R/XYZ 36 179 null]/Next 715 0 R/Parent 704 0 R/Prev 717 0 R/SE 676 0 R/Title(\(III\) The facility shall demonstrate that the staff evaluate the provision 955 of trauma care and patient services, identify opportunities for improvement, 956 develop and implement improvement plans, and evaluate the implementation of 957 those plans \until resolution is achieved. Evidence shall support that aggregate 958 patient data, including identification and tracking of trauma patient complications 959 or variances from standards of care, is continuously reviewed for trends by the 960 trauma mult\idis)>>endobj717 0 obj<</Dest[66 0 R/XYZ 36 193 null]/Next 716 0 R/Parent 704 0 R/Prev 718 0 R/SE 675 0 R/Title( 954 )>>endobj718 0 obj<</Dest[66 0 R/XYZ 36 262 null]/Next 717 0 R/Parent 704 0 R/Prev 719 0 R/SE 674 0 R/Title(\(II\) The program shall reflect the complexity of the facility's trauma 949 plan and the services involved. All facility services \(including those services 950 furnished under contract or arrangement\) shall focus on decreasing deviations 951 from the \trauma standards of care to ensure optimal trauma outcomes, patient 952 safety standards and cost effective care. 953 )>>endobj719 0 obj<</Dest[66 0 R/XYZ 36 276 null]/Next 718 0 R/Parent 704 0 R/Prev 720 0 R/SE 673 0 R/Title( 948 )>>endobj720 0 obj<</Dest[66 0 R/XYZ 36 345 null]/Next 719 0 R/Parent 704 0 R/Prev 721 0 R/SE 672 0 R/Title(\(I\) A facility shall develop, implement, maintain, and evaluate an 943 effective, ongoing, facility-wide, data-driven, outcomes based multidisciplinary 944 quality assessment and performance improvement \(QAPI\) program. 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Established criteria for care 878 of major or severe burn patients and/or a process to expedite the transfer of burn patients 879 to a burn center or higher level of care to include written protocols, written transfer 880 agree\ments, and a regional trauma system transfer plan for patients needing a higher level 881 of care or specialty services. 882 )>>endobj768 0 obj<</Dest[64 0 R/XYZ 36 621 null]/Next 767 0 R/Parent 704 0 R/Prev 769 0 R/SE 608 0 R/Title( 877 )>>endobj769 0 obj<</Dest[64 0 R/XYZ 36 648 null]/Next 768 0 R/Parent 704 0 R/Prev 770 0 R/SE 607 0 R/Title(\(x\) Acute hemodialysis capability. A Transfer plan 875 shall be implemented if there is no capability for this standard. 876 )>>endobj770 0 obj<</Dest[64 0 R/XYZ 36 662 null]/Next 769 0 R/Parent 704 0 R/Prev 771 0 R/SE 606 0 R/Title( 874 )>>endobj771 0 obj<</Dest[64 0 R/XYZ 36 676 null]/Next 770 0 R/Parent 704 0 R/Prev 772 0 R/SE 605 0 R/Title(\(20\) Specialized Capabilities/Services/Units. 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This system shall be continuously monitored by the trauma PI 866 program; 867 )>>endobj778 0 obj<</Dest[62 0 R/XYZ 36 179 null]/Next 777 0 R/Parent 704 0 R/Prev 779 0 R/SE 597 0 R/Title( 863 )>>endobj779 0 obj<</Dest[62 0 R/XYZ 36 193 null]/Next 778 0 R/Parent 704 0 R/Prev 780 0 R/SE 595 0 R/Title(\(I\) Sonography; 862 )>>endobj780 0 obj<</Dest[62 0 R/XYZ 36 207 null]/Next 779 0 R/Parent 704 0 R/Prev 781 0 R/SE 594 0 R/Title( 861 )>>endobj781 0 obj<</Dest[62 0 R/XYZ 36 234 null]/Next 780 0 R/Parent 704 0 R/Prev 782 0 R/SE 593 0 R/Title(\(IV\) Special Radiological Capabilities shall be available for the trauma 859 patient as defined by the facility•s trauma plan to include: 860 )>>endobj782 0 obj<</Dest[62 0 R/XYZ 36 248 null]/Next 781 0 R/Parent 704 0 R/Prev 783 0 R/SE 592 0 R/Title( 858 )>>endobj783 0 obj<</Dest[62 0 R/XYZ 36 290 null]/Next 782 0 R/Parent 704 0 R/Prev 784 0 R/SE 591 0 R/Title(\(III\) Standard Radiological Capability/Services. An in-house 855 technician shall be available 24hours a day or be on-call and promptly available 856 on-site within 30 minutes of request. 857 )>>endobj784 0 obj<</Dest[62 0 R/XYZ 36 303 null]/Next 783 0 R/Parent 704 0 R/Prev 785 0 R/SE 590 0 R/Title( 854 )>>endobj785 0 obj<</Dest[62 0 R/XYZ 36 331 null]/Next 784 0 R/Parent 704 0 R/Prev 786 0 R/SE 589 0 R/Title(\(II\) Clinical Laboratory Service. Laboratory services shall be in-house 852 and available 24 hours per day; 853 )>>endobj786 0 obj<</Dest[62 0 R/XYZ 36 345 null]/Next 785 0 R/Parent 704 0 R/Prev 787 0 R/SE 588 0 R/Title( 851 )>>endobj787 0 obj<</Dest[62 0 R/XYZ 36 372 null]/Next 786 0 R/Parent 704 0 R/Prev 788 0 R/SE 587 0 R/Title(\(I\) Respiratory Services. Respiratory services shall be inhouse and 849 available 24 hours per day. 850 )>>endobj788 0 obj<</Dest[62 0 R/XYZ 36 386 null]/Next 787 0 R/Parent 704 0 R/Prev 789 0 R/SE 586 0 R/Title( 848 )>>endobj789 0 obj<</Dest[62 0 R/XYZ 312 403 null]/Next 788 0 R/Parent 704 0 R/Prev 790 0 R/SE 585 0 R/Title( \(19\) Clinical Support Services. Level III and IV. 847 )>>endobj790 0 obj<</Dest[62 0 R/XYZ 36 414 null]/Next 789 0 R/Parent 704 0 R/Prev 791 0 R/SE 584 0 R/Title( 846 )>>endobj791 0 obj<</Dest[62 0 R/XYZ 36 497 null]/Next 790 0 R/Parent 704 0 R/Prev 792 0 R/SE 583 0 R/Title(\(II\) A Physician credentialed in critical care on duty in the ICU 24 840 hours a day or immediately available from in-hospital and meets the credentialing 841 requirements as defined in the facility trauma program plan. Arrangements for 24-842 hour surg\ical coverage of all trauma patients shall be provided for emergencies 843 and routine care. This system shall be continuously monitored by the trauma PI 844 program; 845 )>>endobj792 0 obj<</Dest[62 0 R/XYZ 36 510 null]/Next 791 0 R/Parent 704 0 R/Prev 793 0 R/SE 582 0 R/Title( 839 )>>endobj793 0 obj<</Dest[62 0 R/XYZ 36 579 null]/Next 792 0 R/Parent 704 0 R/Prev 794 0 R/SE 581 0 R/Title(\(I\) Designated surgical director or surgical co-director responsible for 834 setting policies, developing protocols and management guidelines related to 835 trauma ICU patients. A physician providing this coverage must be a 836 board certified or board-\eligible surgeon and meets the credentialing requirements 837 as defined in the facility trauma program plan; or 838 )>>endobj794 0 obj<</Dest[62 0 R/XYZ 36 593 null]/Next 793 0 R/Parent 704 0 R/Prev 795 0 R/SE 580 0 R/Title( 833 )>>endobj795 0 obj<</Dest[62 0 R/XYZ 36 662 null]/Next 794 0 R/Parent 704 0 R/Prev 796 0 R/SE 579 0 R/Title(\(18\) Intensive Care Capability for a Level III. Intensive care capability shall be 828 available for the trauma critical care patient and interventions as defined by the facility•s 829 trauma plan to include resuscitation, temperature warming and cooli\ng management, 830 hemorrhage control, hemodynamic monitoring and orthopedic splinting to ensure that 831 trauma standards of care are met. 832 )>>endobj796 0 obj<</Dest[62 0 R/XYZ 36 676 null]/Next 795 0 R/Parent 704 0 R/Prev 797 0 R/SE 578 0 R/Title( 827 )>>endobj797 0 obj<</Dest[62 0 R/XYZ 36 704 null]/Next 796 0 R/Parent 704 0 R/Prev 798 0 R/SE 577 0 R/Title(\(IV\) Appropriate equipment to ensure that trauma 825 standards of care are met 826 )>>endobj798 0 obj<</Dest[62 0 R/XYZ 36 717 null]/Next 797 0 R/Parent 704 0 R/Prev 799 0 R/SE 575 0 R/Title( 824 )>>endobj799 0 obj<</Dest[59 0 R/XYZ 36 110 null]/Next 798 0 R/Parent 704 0 R/Prev 800 0 R/SE 574 0 R/Title(\(III\) Registered nurses and other essential personnel 822 available 24 hours a day; 823 )>>endobj800 0 obj<</Dest[59 0 R/XYZ 36 124 null]/Next 799 0 R/Parent 704 0 R/Prev 801 0 R/SE 573 0 R/Title( 821 )>>endobj801 0 obj<</Dest[59 0 R/XYZ 36 152 null]/Next 800 0 R/Parent 704 0 R/Prev 802 0 R/SE 572 0 R/Title(\(II\) Post-Anesthesia Care Unit. 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763 )>>endobj844 0 obj<</Dest[57 0 R/XYZ 36 331 null]/Next 843 0 R/Parent 704 0 R/Prev 845 0 R/SE 528 0 R/Title( 760 )>>endobj845 0 obj<</Dest[57 0 R/XYZ 36 345 null]/Next 844 0 R/Parent 704 0 R/Prev 846 0 R/SE 527 0 R/Title(\(i\) Standard: Emergency Department Equipment. 759 )>>endobj846 0 obj<</Dest[57 0 R/XYZ 36 359 null]/Next 845 0 R/Parent 704 0 R/Prev 847 0 R/SE 526 0 R/Title( 758 )>>endobj847 0 obj<</Dest[57 0 R/XYZ 36 372 null]/Next 846 0 R/Parent 704 0 R/Prev 848 0 R/SE 525 0 R/Title(\(A\) Equipment. 757 )>>endobj848 0 obj<</Dest[57 0 R/XYZ 36 386 null]/Next 847 0 R/Parent 704 0 R/Prev 849 0 R/SE 524 0 R/Title( 756 )>>endobj849 0 obj<</Dest[57 0 R/XYZ 36 441 null]/Next 848 0 R/Parent 704 0 R/Prev 850 0 R/SE 523 0 R/Title(\(16\) Emergency Department Equipment and Services. Equipment and services 752 for the evaluation, resuscitation, and life support for critically or seriously injured patients of all 753 ages shall be available for resuscitation, temperature warming and \cooling management, 754 hemorrhage control, hemodynamic monitoring and orthopedic splinting. 755 )>>endobj850 0 obj<</Dest[57 0 R/XYZ 36 455 null]/Next 849 0 R/Parent 704 0 R/Prev 851 0 R/SE 522 0 R/Title( 751 )>>endobj851 0 obj<</Dest[57 0 R/XYZ 36 483 null]/Next 850 0 R/Parent 704 0 R/Prev 852 0 R/SE 521 0 R/Title(\(15\) Pre-hospital EMS Communication. There shall be two-way 749 communication with all pre-hospital emergency medical services vehicles. 750 )>>endobj852 0 obj<</Dest[57 0 R/XYZ 36 497 null]/Next 851 0 R/Parent 704 0 R/Prev 853 0 R/SE 520 0 R/Title( 748 )>>endobj853 0 obj<</Dest[57 0 R/XYZ 36 510 null]/Next 852 0 R/Parent 704 0 R/Prev 854 0 R/SE 519 0 R/Title(\(C\) other office approved equivalent course. 747 )>>endobj854 0 obj<</Dest[57 0 R/XYZ 36 524 null]/Next 853 0 R/Parent 704 0 R/Prev 855 0 R/SE 518 0 R/Title( 746 )>>endobj855 0 obj<</Dest[57 0 R/XYZ 36 552 null]/Next 854 0 R/Parent 704 0 R/Prev 856 0 R/SE 517 0 R/Title(\(A\) the Association for the Advancement of Automotive Medicine 744 \(AAAM\) course, or 745 )>>endobj856 0 obj<</Dest[57 0 R/XYZ 36 566 null]/Next 855 0 R/Parent 704 0 R/Prev 857 0 R/SE 516 0 R/Title( 743 )>>endobj857 0 obj<</Dest[57 0 R/XYZ 257 610 null]/Next 856 0 R/Parent 704 0 R/Prev 858 0 R/SE 515 0 R/Title(\(14\) Trauma Registrar \(Level III only\). There shall be an identified Trauma 740 Registrar, who is separate from but supervised by the TPM, who has had appropriate training 741 within 24 months of hire into the position of trauma registrar which inclu\des: 742 )>>endobj858 0 obj<</Dest[57 0 R/XYZ 36 621 null]/Next 857 0 R/Parent 704 0 R/Prev 859 0 R/SE 514 0 R/Title( 739 )>>endobj859 0 obj<</Dest[57 0 R/XYZ 36 648 null]/Next 858 0 R/Parent 704 0 R/Prev 860 0 R/SE 513 0 R/Title(\(C\) Data validation. The Trauma Registrar must participate in ongoing 737 data validation through the department and/or the RAC PI committee. 738 )>>endobj860 0 obj<</Dest[57 0 R/XYZ 36 662 null]/Next 859 0 R/Parent 704 0 R/Prev 861 0 R/SE 512 0 R/Title( 736 )>>endobj861 0 obj<</Dest[57 0 R/XYZ 36 704 null]/Next 860 0 R/Parent 704 0 R/Prev 862 0 R/SE 511 0 R/Title(\(B\) Identified Trauma Registrar who has appropriate education, 733 training in injury severity scaling, and four hours of continuing education annually specific to 734 trauma data quality. 735 )>>endobj862 0 obj<</Dest[57 0 R/XYZ 36 717 null]/Next 861 0 R/Parent 704 0 R/Prev 863 0 R/SE 509 0 R/Title( 732 )>>endobj863 0 obj<</Dest[50 0 R/XYZ 36 124 null]/Next 862 0 R/Parent 704 0 R/Prev 864 0 R/SE 508 0 R/Title(\(ii\) Re-designation. Data shall be uploaded to the Texas 729 EMS/Trauma Registry as indicated in Chapter 103, Injury Prevention and Control of this title 730 within 45 days of patient discharge with a 90% acceptance rate. 731 )>>endobj864 0 obj<</Dest[50 0 R/XYZ 36 138 null]/Next 863 0 R/Parent 704 0 R/Prev 865 0 R/SE 507 0 R/Title( 728 )>>endobj865 0 obj<</Dest[50 0 R/XYZ 36 207 null]/Next 864 0 R/Parent 704 0 R/Prev 866 0 R/SE 506 0 R/Title(\(i\) Initial designation. Six months of data prior to the initial 723 designation survey must be uploaded to the Texas EMS/Trauma System Registry. Subsequent to 724 initial designation, data shall be uploaded to the Texas EMS/Trauma Registry as indicated\ in 725 Chapter 103, Injury Prevention and Control of this title within 45 days of discharge with a 90% 726 acceptance or accuracy rate. 727 )>>endobj866 0 obj<</Dest[50 0 R/XYZ 36 221 null]/Next 865 0 R/Parent 704 0 R/Prev 867 0 R/SE 505 0 R/Title( 722 )>>endobj867 0 obj<</Dest[50 0 R/XYZ 36 234 null]/Next 866 0 R/Parent 704 0 R/Prev 868 0 R/SE 504 0 R/Title(\(A\) Data submission for designation purposes. 721 )>>endobj868 0 obj<</Dest[50 0 R/XYZ 36 248 null]/Next 867 0 R/Parent 704 0 R/Prev 869 0 R/SE 503 0 R/Title( 720 )>>endobj869 0 obj<</Dest[50 0 R/XYZ 36 276 null]/Next 868 0 R/Parent 704 0 R/Prev 870 0 R/SE 502 0 R/Title(\(13\) Texas EMS/Trauma Registry Requirements. Any designated trauma facility 718 must participate in the Texas EMS/Trauma Registry. Participation shall include: 719 )>>endobj870 0 obj<</Dest[50 0 R/XYZ 36 290 null]/Next 869 0 R/Parent 704 0 R/Prev 871 0 R/SE 501 0 R/Title( 717 )>>endobj871 0 obj<</Dest[50 0 R/XYZ 36 345 null]/Next 870 0 R/Parent 704 0 R/Prev 872 0 R/SE 500 0 R/Title(\(H\) A stand-alone children•s facility shall have documentation that 100% of nursing staff 713 who care for trauma patients have successfully completed and hold current credentials in a 714 nationally recognized pediatric advanced life support course \(e\.g. PALS or ENPC\) and TNCC or 715 ATCN or a DSHS-approved equivalent, within 18 months of date of employment in the ED. 716 )>>endobj872 0 obj<</Dest[50 0 R/XYZ 36 361 null]/Next 871 0 R/Parent 704 0 R/Prev 873 0 R/SE 499 0 R/Title( 712 )>>endobj873 0 obj<</Dest[50 0 R/XYZ 36 441 null]/Next 872 0 R/Parent 704 0 R/Prev 874 0 R/SE 498 0 R/Title(\(G\) documentation that 100% of nursing staff working in the 706 Emergency Department \(ED\) and responding to trauma activations or caring for trauma patients 707 have successfully completed and hold current credentials in an advanced cardiac life suppo\rt 708 course \(e.g. ACLS or hospital equivalent\), a nationally recognized pediatric advanced life 709 support course \(e.g. PALS or ENPC\) and TNCC or ATCN or a DSHS-approved equivalent, 710 within 18 months of date of employment in the ED. 711 )>>endobj874 0 obj<</Dest[50 0 R/XYZ 36 455 null]/Next 873 0 R/Parent 704 0 R/Prev 875 0 R/SE 497 0 R/Title( 705 )>>endobj875 0 obj<</Dest[50 0 R/XYZ 36 524 null]/Next 874 0 R/Parent 704 0 R/Prev 876 0 R/SE 496 0 R/Title(\(F\) nursing documentation for trauma patients is systematic and meets 700 the trauma registry guidelines, includes at a minimum:: the sequence of care, primary and 701 secondary survey with interventions, outcomes, serial vital signs, GCS, consulting s\ervices 702 assessment, plan of care with disposition and documents the response time of all trauma team 703 members. 704 )>>endobj876 0 obj<</Dest[50 0 R/XYZ 36 538 null]/Next 875 0 R/Parent 704 0 R/Prev 877 0 R/SE 495 0 R/Title( 699 )>>endobj877 0 obj<</Dest[50 0 R/XYZ 36 607 null]/Next 876 0 R/Parent 704 0 R/Prev 878 0 R/SE 494 0 R/Title(\(E\) a minimum of two registered nurses shall participate in initial 694 resuscitations for full and limited or trauma activations, have successfully completed and hold 695 current credentials in an advanced cardiac life support course \(ACLS\); a nation\ally 696 recognized pediatric advanced life support course \( PALS or ENPC\); and TNCC or ATCN; or an 697 office approved equivalent for each course; 698 )>>endobj878 0 obj<</Dest[50 0 R/XYZ 36 621 null]/Next 877 0 R/Parent 704 0 R/Prev 879 0 R/SE 493 0 R/Title( 693 )>>endobj879 0 obj<</Dest[50 0 R/XYZ 36 662 null]/Next 878 0 R/Parent 704 0 R/Prev 880 0 R/SE 492 0 R/Title(\(D\) a written plan, developed by the hospital, for acquisition of 690 additional staff on a 24 hour basis to support units with increased patient acuity, multiple 691 emergency procedures and admissions \(i.e. written surge plan.\); 692 )>>endobj880 0 obj<</Dest[50 0 R/XYZ 36 676 null]/Next 879 0 R/Parent 704 0 R/Prev 881 0 R/SE 491 0 R/Title( 689 )>>endobj881 0 obj<</Dest[50 0 R/XYZ 36 717 null]/Next 880 0 R/Parent 704 0 R/Prev 882 0 R/SE 489 0 R/Title(\(C\) a facility approved acuity-based patient classification system is 686 utilized to define workload and number of nursing staff to provide safe patient care for all trauma 687 patients throughout their hospitalization; 688 )>>endobj882 0 obj<</Dest[48 0 R/XYZ 36 96 null]/Next 881 0 R/Parent 704 0 R/Prev 883 0 R/SE 488 0 R/Title( 685 )>>endobj883 0 obj<</Dest[48 0 R/XYZ 36 124 null]/Next 882 0 R/Parent 704 0 R/Prev 884 0 R/SE 487 0 R/Title(\(B\) written standards on nursing care for trauma patients for all units 683 \(i.e. ED, ICU, OR, PACU, general inpatient\) in the trauma facility shall be implemented; 684 )>>endobj884 0 obj<</Dest[48 0 R/XYZ 36 138 null]/Next 883 0 R/Parent 704 0 R/Prev 885 0 R/SE 486 0 R/Title( 682 )>>endobj885 0 obj<</Dest[48 0 R/XYZ 36 179 null]/Next 884 0 R/Parent 704 0 R/Prev 886 0 R/SE 485 0 R/Title(\(A\) all nurses caring for trauma patients throughout the continuum of 679 care have ongoing documented knowledge and skills in trauma nursing for patients of all ages to 680 include trauma specific orientation, annual clinical competencies, and continui\ng education; 681 )>>endobj886 0 obj<</Dest[48 0 R/XYZ 36 193 null]/Next 885 0 R/Parent 704 0 R/Prev 887 0 R/SE 484 0 R/Title( 678 )>>endobj887 0 obj<</Dest[48 0 R/XYZ 36 221 null]/Next 886 0 R/Parent 704 0 R/Prev 888 0 R/SE 483 0 R/Title(\(12\) Nursing Services for all critical care and patient care areas shall provide 676 evidence of the following: 677 )>>endobj888 0 obj<</Dest[48 0 R/XYZ 36 234 null]/Next 887 0 R/Parent 704 0 R/Prev 889 0 R/SE 482 0 R/Title( 675 )>>endobj889 0 obj<</Dest[48 0 R/XYZ 36 290 null]/Next 888 0 R/Parent 704 0 R/Prev 890 0 R/SE 481 0 R/Title(\(v\) has completed a course designed for his/her role which 671 provides essential information of a trauma PI program to include trauma 672 outcomes and performance improvement; Trauma Outcomes Performance 673 Improvement Course \(TOPIC\); or an office a\pproved equivalent course. 674 )>>endobj890 0 obj<</Dest[48 0 R/XYZ 36 303 null]/Next 889 0 R/Parent 704 0 R/Prev 891 0 R/SE 480 0 R/Title( 670 )>>endobj891 0 obj<</Dest[48 0 R/XYZ 36 359 null]/Next 890 0 R/Parent 704 0 R/Prev 892 0 R/SE 479 0 R/Title(\(iv\) has completed a course designed for his/her role which 666 provides essential information on the structure, process, organization and 667 administrative responsibilities of a trauma program; Trauma Coordinators 668 Core Course \(TCCC\); or an offic\e approved equivalent course; 669 )>>endobj892 0 obj<</Dest[48 0 R/XYZ 36 372 null]/Next 891 0 R/Parent 704 0 R/Prev 893 0 R/SE 478 0 R/Title( 665 )>>endobj893 0 obj<</Dest[48 0 R/XYZ 36 414 null]/Next 892 0 R/Parent 704 0 R/Prev 894 0 R/SE 477 0 R/Title(\(iii\) participation in a leadership role in the facility including 662 the facility-wide QAPI Committee, community, and regional emergency management \(disaster\) 663 response committee; 664 )>>endobj894 0 obj<</Dest[48 0 R/XYZ 36 428 null]/Next 893 0 R/Parent 704 0 R/Prev 895 0 R/SE 476 0 R/Title( 661 )>>endobj895 0 obj<</Dest[48 0 R/XYZ 36 469 null]/Next 894 0 R/Parent 704 0 R/Prev 896 0 R/SE 475 0 R/Title(\(ii\) monitoring trauma patient care from ED arrival through 658 operative intervention\(s\), ICU care, stabilization, rehabilitation care, and discharge, including the 659 trauma performance improvement \(PI\) program; 660 )>>endobj896 0 obj<</Dest[48 0 R/XYZ 36 483 null]/Next 895 0 R/Parent 704 0 R/Prev 897 0 R/SE 474 0 R/Title( 657 )>>endobj897 0 obj<</Count 2/Dest[48 0 R/XYZ 36 511 null]/First 898 0 R/Last 898 0 R/Next 896 0 R/Parent 704 0 R/Prev 899 0 R/SE 471 0 R/Title(\(i\) monitoring the clinical outcomes, direction and oversight of 655 the trauma program. 656 )>>endobj898 0 obj<</Count 1/Dest[48 0 R/XYZ 36 511 null]/First 1278 0 R/Last 1278 0 R/Parent 897 0 R/SE 472 0 R/Title(\(i\) monitoring the clinical outcomes, direction and oversight of 655 the trauma program. 656 )>>endobj899 0 obj<</Dest[48 0 R/XYZ 36 527 null]/Next 897 0 R/Parent 704 0 R/Prev 900 0 R/SE 470 0 R/Title( 654 )>>endobj900 0 obj<</Dest[48 0 R/XYZ 36 552 null]/Next 899 0 R/Parent 704 0 R/Prev 901 0 R/SE 469 0 R/Title(\(B\) The Trauma Program Manager is responsible for the integration of 652 trauma nursing standards of care. The responsibilities and authority of the TPM shall include: 653 )>>endobj901 0 obj<</Dest[48 0 R/XYZ 36 566 null]/Next 900 0 R/Parent 704 0 R/Prev 902 0 R/SE 468 0 R/Title( 651 )>>endobj902 0 obj<</Dest[48 0 R/XYZ 36 607 null]/Next 901 0 R/Parent 704 0 R/Prev 903 0 R/SE 467 0 R/Title(\(iii\) is current in a nationally recognized pediatric advanced life 648 support course \(\(Pediatric Advanced Life Support \(PALS\) or the Emergency Nurse Pediatric 649 Course \(ENPC\)\); 650 )>>endobj903 0 obj<</Dest[48 0 R/XYZ 36 621 null]/Next 902 0 R/Parent 704 0 R/Prev 904 0 R/SE 466 0 R/Title( 647 )>>endobj904 0 obj<</Dest[48 0 R/XYZ 36 648 null]/Next 903 0 R/Parent 704 0 R/Prev 905 0 R/SE 465 0 R/Title(\(ii\) is current in the Trauma Nurse Core Course \(TNCC\) or 645 Advanced Trauma Course for Nurses \(ATCN\) or an office approved equivalent; 646 )>>endobj905 0 obj<</Dest[48 0 R/XYZ 36 662 null]/Next 904 0 R/Parent 704 0 R/Prev 906 0 R/SE 464 0 R/Title( 644 )>>endobj906 0 obj<</Dest[48 0 R/XYZ 36 676 null]/Next 905 0 R/Parent 704 0 R/Prev 907 0 R/SE 463 0 R/Title(\(i\) shall be a registered nurse; 643 )>>endobj907 0 obj<</Dest[48 0 R/XYZ 36 690 null]/Next 906 0 R/Parent 704 0 R/Prev 908 0 R/SE 462 0 R/Title( 642 )>>endobj908 0 obj<</Dest[48 0 R/XYZ 36 704 null]/Next 907 0 R/Parent 704 0 R/Prev 909 0 R/SE 461 0 R/Title( \(B\) The TPM: 641 )>>endobj909 0 obj<</Dest[48 0 R/XYZ 36 717 null]/Next 908 0 R/Parent 704 0 R/Prev 910 0 R/SE 459 0 R/Title( 640 )>>endobj910 0 obj<</Dest[46 0 R/XYZ 36 110 null]/Next 909 0 R/Parent 704 0 R/Prev 911 0 R/SE 458 0 R/Title(\(A\) There shall be an identified Trauma Program Manager responsible 638 for trauma patient care throughout the continuum of care and through discharge. 639 )>>endobj911 0 obj<</Dest[46 0 R/XYZ 36 124 null]/Next 910 0 R/Parent 704 0 R/Prev 912 0 R/SE 457 0 R/Title( 637 )>>endobj912 0 obj<</Dest[46 0 R/XYZ 36 138 null]/Next 911 0 R/Parent 704 0 R/Prev 913 0 R/SE 456 0 R/Title(\(11\) Trauma Program Manager \(TPM\). 636 )>>endobj913 0 obj<</Dest[46 0 R/XYZ 36 152 null]/Next 912 0 R/Parent 704 0 R/Prev 914 0 R/SE 455 0 R/Title( 635 )>>endobj914 0 obj<</Dest[46 0 R/XYZ 36 221 null]/Next 913 0 R/Parent 704 0 R/Prev 915 0 R/SE 454 0 R/Title(\(10\) Nursing Staff. As part of the facility•s trauma program approved by the 630 governing body, the program will have an identified Trauma Program Manager with equivalent 631 authority and responsibility as granted to other department or nurse manage\rs. There shall be a 632 demonstrated commitment by the facility for furthering the education and understanding of 633 trauma standards of care for all nursing staff caring for the trauma patient. 634 )>>endobj915 0 obj<</Dest[46 0 R/XYZ 36 234 null]/Next 914 0 R/Parent 704 0 R/Prev 916 0 R/SE 453 0 R/Title( 629 )>>endobj916 0 obj<</Dest[46 0 R/XYZ 36 290 null]/Next 915 0 R/Parent 704 0 R/Prev 917 0 R/SE 452 0 R/Title(\(B\) The rate of change in interpretation of radiologic studies must be 625 routinely monitored and reviewed with the radiology department. Identified cases should be 626 reviewed to determine the reason for misinterpretation, adverse outcomes, and oppo\rtunities for 627 improvement. 628 )>>endobj917 0 obj<</Dest[46 0 R/XYZ 36 303 null]/Next 916 0 R/Parent 704 0 R/Prev 918 0 R/SE 451 0 R/Title( 624 )>>endobj918 0 obj<</Count 2/Dest[46 0 R/XYZ 36 345 null]/First 919 0 R/Last 919 0 R/Next 917 0 R/Parent 704 0 R/Prev 920 0 R/SE 448 0 R/Title(\(A\) A radiologist shall be on-call and promptly available within 30 621 minutes of request from inside or outside the hospital. This system 622 shall be continuously monitored by the trauma PI program. 623 )>>endobj919 0 obj<</Count 1/Dest[46 0 R/XYZ 36 345 null]/First 1277 0 R/Last 1277 0 R/Parent 918 0 R/SE 449 0 R/Title(\(A\) A radiologist shall be on-call and promptly available within 30 621 minutes of request from inside or outside the hospital. This system 622 shall be continuously monitored by the trauma PI program. 623 )>>endobj920 0 obj<</Dest[46 0 R/XYZ 36 361 null]/Next 918 0 R/Parent 704 0 R/Prev 921 0 R/SE 447 0 R/Title( 620 )>>endobj921 0 obj<</Dest[46 0 R/XYZ 36 375 null]/Next 920 0 R/Parent 704 0 R/Prev 922 0 R/SE 446 0 R/Title(\(9\) Radiology Services. 619 )>>endobj922 0 obj<</Dest[46 0 R/XYZ 36 386 null]/Next 921 0 R/Parent 704 0 R/Prev 923 0 R/SE 445 0 R/Title( 618 )>>endobj923 0 obj<</Dest[46 0 R/XYZ 36 469 null]/Next 922 0 R/Parent 704 0 R/Prev 924 0 R/SE 444 0 R/Title(\(B\) Advanced Practice clinicians \(advanced practice registered nurses 612 or physician assistants\) utilized in the care of major and/or severe trauma patients, shall not be a 613 substitute for the required physician response, in patient care plannin\g nor in QAPI activities. 614 Any Advanced Practice clinician who provides care to trauma patients shall be current in ATLS 615 and be appropriately credentialed by the Texas Board of Nursing \(TBON\) or the Texas Medical 616 Board \(TMB\) respectively. \617 )>>endobj924 0 obj<</Dest[46 0 R/XYZ 36 483 null]/Next 923 0 R/Parent 704 0 R/Prev 925 0 R/SE 443 0 R/Title( 611 )>>endobj925 0 obj<</Dest[46 0 R/XYZ 36 510 null]/Next 924 0 R/Parent 704 0 R/Prev 926 0 R/SE 442 0 R/Title(\(viii\) a designated liaison shall attend at least 50% of the trauma 609 multidisciplinary peer review trauma committee meetings. 610 )>>endobj926 0 obj<</Dest[46 0 R/XYZ 36 538 null]/Next 925 0 R/Parent 704 0 R/Prev 927 0 R/SE 441 0 R/Title(\(vii\) participate in the trauma QAPI/Multidisciplinary PI 607 program; and 608 )>>endobj927 0 obj<</Dest[46 0 R/XYZ 36 552 null]/Next 926 0 R/Parent 704 0 R/Prev 928 0 R/SE 440 0 R/Title( 606 )>>endobj928 0 obj<</Dest[46 0 R/XYZ 36 566 null]/Next 927 0 R/Parent 704 0 R/Prev 929 0 R/SE 439 0 R/Title(\(vi\) maintain compliance with trauma protocols; 605 )>>endobj929 0 obj<</Dest[46 0 R/XYZ 36 579 null]/Next 928 0 R/Parent 704 0 R/Prev 930 0 R/SE 438 0 R/Title( 604 )>>endobj930 0 obj<</Dest[46 0 R/XYZ 36 593 null]/Next 929 0 R/Parent 704 0 R/Prev 931 0 R/SE 437 0 R/Title(\(iv\) be appropriately credentialed through the trauma program; 603 )>>endobj931 0 obj<</Dest[46 0 R/XYZ 36 607 null]/Next 930 0 R/Parent 704 0 R/Prev 932 0 R/SE 436 0 R/Title( 602 )>>endobj932 0 obj<</Dest[46 0 R/XYZ 36 648 null]/Next 931 0 R/Parent 704 0 R/Prev 933 0 R/SE 435 0 R/Title(\(iii\) prior to \(the effective date of this rule\) have continuously 599 provided anesthesia coverage at the designated facility for the last consecutive five years; 600 average at least 16 hours of continuing medical education annually; and 601 )>>endobj933 0 obj<</Dest[46 0 R/XYZ 36 662 null]/Next 932 0 R/Parent 704 0 R/Prev 934 0 R/SE 434 0 R/Title( 598 )>>endobj934 0 obj<</Dest[46 0 R/XYZ 36 690 null]/Next 933 0 R/Parent 704 0 R/Prev 935 0 R/SE 433 0 R/Title(\(ii\) be a candidate in the American Board of Anesthesiology 596 examination system; or 597 )>>endobj935 0 obj<</Dest[46 0 R/XYZ 36 704 null]/Next 934 0 R/Parent 704 0 R/Prev 936 0 R/SE 432 0 R/Title( 595 )>>endobj936 0 obj<</Dest[46 0 R/XYZ 36 717 null]/Next 935 0 R/Parent 704 0 R/Prev 937 0 R/SE 430 0 R/Title(\(i\) be a board certified anesthesiologist; or 594 )>>endobj937 0 obj<</Dest[44 0 R/XYZ 36 96 null]/Next 936 0 R/Parent 704 0 R/Prev 938 0 R/SE 429 0 R/Title( 593 )>>endobj938 0 obj<</Dest[44 0 R/XYZ 36 110 null]/Next 937 0 R/Parent 704 0 R/Prev 939 0 R/SE 428 0 R/Title(\(A\) The anesthesiologist providing trauma coverage shall: 592 )>>endobj939 0 obj<</Dest[44 0 R/XYZ 36 124 null]/Next 938 0 R/Parent 704 0 R/Prev 940 0 R/SE 427 0 R/Title( 591 )>>endobj940 0 obj<</Dest[44 0 R/XYZ 36 152 null]/Next 939 0 R/Parent 704 0 R/Prev 941 0 R/SE 426 0 R/Title(\(8\) Anesthesia Services. If the facility furnishes anesthesia services, it shall do 589 so in compliance with 25 TAC 133.41 Hospital Functions and Services. 590 )>>endobj941 0 obj<</Dest[44 0 R/XYZ 36 165 null]/Next 940 0 R/Parent 704 0 R/Prev 942 0 R/SE 425 0 R/Title( 588 )>>endobj942 0 obj<</Dest[44 0 R/XYZ 36 207 null]/Next 941 0 R/Parent 704 0 R/Prev 943 0 R/SE 424 0 R/Title(\(H\) participate in the trauma QAPI/multidisciplinary PI program and a 585 designated liaison shall attend at least 50% of the trauma multidisciplinary PI and peer review 586 committee meetings. 587 )>>endobj943 0 obj<</Dest[44 0 R/XYZ 36 221 null]/Next 942 0 R/Parent 704 0 R/Prev 944 0 R/SE 423 0 R/Title( 584 )>>endobj944 0 obj<</Dest[44 0 R/XYZ 36 234 null]/Next 943 0 R/Parent 704 0 R/Prev 945 0 R/SE 422 0 R/Title(\(G\) maintain compliance with trauma protocols; and 583 )>>endobj945 0 obj<</Dest[44 0 R/XYZ 36 248 null]/Next 944 0 R/Parent 704 0 R/Prev 946 0 R/SE 421 0 R/Title( 582 )>>endobj946 0 obj<</Dest[44 0 R/XYZ 36 276 null]/Next 945 0 R/Parent 704 0 R/Prev 947 0 R/SE 420 0 R/Title(\(F\) average at least 16 hours of trauma-related continuing medical 580 education annually; 581 )>>endobj947 0 obj<</Dest[44 0 R/XYZ 36 290 null]/Next 946 0 R/Parent 704 0 R/Prev 948 0 R/SE 419 0 R/Title( 579 )>>endobj948 0 obj<</Dest[44 0 R/XYZ 36 303 null]/Next 947 0 R/Parent 704 0 R/Prev 949 0 R/SE 418 0 R/Title(\(E\) be appropriately credentialed through the trauma program; 578 )>>endobj949 0 obj<</Dest[44 0 R/XYZ 36 317 null]/Next 948 0 R/Parent 704 0 R/Prev 950 0 R/SE 417 0 R/Title( 577 )>>endobj950 0 obj<</Dest[44 0 R/XYZ 36 359 null]/Next 949 0 R/Parent 704 0 R/Prev 951 0 R/SE 416 0 R/Title(\(D\) be board eligible in their applicable specialty and currently 574 credentialed in Advanced Trauma Life Support \(ATLS\) or an equivalent course approved by the 575 office; and 576 )>>endobj951 0 obj<</Dest[44 0 R/XYZ 36 372 null]/Next 950 0 R/Parent 704 0 R/Prev 952 0 R/SE 415 0 R/Title( 573 )>>endobj952 0 obj<</Dest[44 0 R/XYZ 36 414 null]/Next 951 0 R/Parent 704 0 R/Prev 953 0 R/SE 414 0 R/Title(\(C\) prior to \(the effective date of this rule\) have continuously provided 570 trauma coverage in the emergency department at the designated facility for the last consecutive 571 five years and be currently credentialed in Advanced Trauma Life Support \\(ATLS\); or 572 )>>endobj953 0 obj<</Dest[44 0 R/XYZ 36 428 null]/Next 952 0 R/Parent 704 0 R/Prev 954 0 R/SE 413 0 R/Title( 569 )>>endobj954 0 obj<</Dest[44 0 R/XYZ 36 455 null]/Next 953 0 R/Parent 704 0 R/Prev 955 0 R/SE 412 0 R/Title(\(B\) be board eligible in emergency medicine and currently credentialed 567 in Advanced Trauma Life Support \(ATLS\) or an equivalent course approved by the office; or 568 )>>endobj955 0 obj<</Dest[44 0 R/XYZ 36 469 null]/Next 954 0 R/Parent 704 0 R/Prev 956 0 R/SE 411 0 R/Title( 566 )>>endobj956 0 obj<</Dest[44 0 R/XYZ 36 497 null]/Next 955 0 R/Parent 704 0 R/Prev 957 0 R/SE 410 0 R/Title(\(A\) be board certified in emergency medicine and have successfully 564 completed ATLS; or 565 )>>endobj957 0 obj<</Dest[44 0 R/XYZ 36 510 null]/Next 956 0 R/Parent 704 0 R/Prev 958 0 R/SE 409 0 R/Title( 563 )>>endobj958 0 obj<</Dest[44 0 R/XYZ 36 538 null]/Next 957 0 R/Parent 704 0 R/Prev 959 0 R/SE 408 0 R/Title(\(7\) Emergency Medicine. Any emergency medicine physician who is providing 561 trauma coverage shall be in-house 24 hours a day and shall: 562 )>>endobj959 0 obj<</Dest[44 0 R/XYZ 36 552 null]/Next 958 0 R/Parent 704 0 R/Prev 960 0 R/SE 407 0 R/Title( 560 )>>endobj960 0 obj<</Dest[44 0 R/XYZ 36 593 null]/Next 959 0 R/Parent 704 0 R/Prev 961 0 R/SE 406 0 R/Title(\(G\) at a minimum, orthopedic surgeons and neurosurgeons, participate 557 in the published, on-call schedule and backup on-call schedule or plan readily available to all 558 staff to obtain specialty surgical care. 559 )>>endobj961 0 obj<</Dest[44 0 R/XYZ 36 607 null]/Next 960 0 R/Parent 704 0 R/Prev 962 0 R/SE 405 0 R/Title( 556 )>>endobj962 0 obj<</Dest[44 0 R/XYZ 36 648 null]/Next 961 0 R/Parent 704 0 R/Prev 963 0 R/SE 404 0 R/Title(\(F\) participate in the trauma QAPI/Multidisciplinary PI program and a 553 designated liaison shall attend at least 50% of the trauma Multidisciplinary and peer review 554 trauma committee meetings; and 555 )>>endobj963 0 obj<</Dest[44 0 R/XYZ 36 662 null]/Next 962 0 R/Parent 704 0 R/Prev 964 0 R/SE 403 0 R/Title( 552 )>>endobj964 0 obj<</Dest[44 0 R/XYZ 36 676 null]/Next 963 0 R/Parent 704 0 R/Prev 965 0 R/SE 402 0 R/Title(\(E\) maintain compliance with trauma protocols; 551 )>>endobj965 0 obj<</Dest[44 0 R/XYZ 36 690 null]/Next 964 0 R/Parent 704 0 R/Prev 966 0 R/SE 401 0 R/Title( 550 )>>endobj966 0 obj<</Dest[44 0 R/XYZ 36 717 null]/Next 965 0 R/Parent 704 0 R/Prev 967 0 R/SE 399 0 R/Title(\(D\) average at least 16hours of trauma-related continuing medical 548 education annually; 549 )>>endobj967 0 obj<</Dest[42 0 R/XYZ 36 110 null]/Next 966 0 R/Parent 704 0 R/Prev 968 0 R/SE 398 0 R/Title( 547 )>>endobj968 0 obj<</Dest[42 0 R/XYZ 36 124 null]/Next 967 0 R/Parent 704 0 R/Prev 969 0 R/SE 397 0 R/Title(\(C\) be appropriately credentialed through the trauma service; 546 )>>endobj969 0 obj<</Dest[42 0 R/XYZ 36 141 null]/Next 968 0 R/Parent 704 0 R/Prev 970 0 R/SE 396 0 R/Title( 545 )>>endobj970 0 obj<</Dest[42 0 R/XYZ 36 179 null]/Next 969 0 R/Parent 704 0 R/Prev 971 0 R/SE 395 0 R/Title(\(B\) prior to \(the effective date of this rule\) have continuously provided 542 trauma coverage and participated in trauma call at the designated facility for the last consecutive 543 five years; and 544 )>>endobj971 0 obj<</Dest[42 0 R/XYZ 36 193 null]/Next 970 0 R/Parent 704 0 R/Prev 972 0 R/SE 394 0 R/Title( 541 )>>endobj972 0 obj<</Dest[42 0 R/XYZ 36 221 null]/Next 971 0 R/Parent 704 0 R/Prev 973 0 R/SE 393 0 R/Title(\(A\) be board certified in the applicable surgical specialty; or be board 539 eligible in the applicable surgical specialty; or 540 )>>endobj973 0 obj<</Dest[42 0 R/XYZ 36 248 null]/Next 972 0 R/Parent 704 0 R/Prev 974 0 R/SE 392 0 R/Title(\(6\) Trauma Surgical Specialty Services. Orthopedic and Neurosurgery surgeons 537 shall: 538 )>>endobj974 0 obj<</Dest[42 0 R/XYZ 36 262 null]/Next 973 0 R/Parent 704 0 R/Prev 975 0 R/SE 391 0 R/Title( 536 )>>endobj975 0 obj<</Dest[42 0 R/XYZ 36 290 null]/Next 974 0 R/Parent 704 0 R/Prev 976 0 R/SE 390 0 R/Title(\(5\) In addition to continuous general surgery coverage the facility shall have 534 continuous orthopedic surgical coverage. 535 )>>endobj976 0 obj<</Dest[42 0 R/XYZ 36 303 null]/Next 975 0 R/Parent 704 0 R/Prev 977 0 R/SE 389 0 R/Title( 533 )>>endobj977 0 obj<</Dest[42 0 R/XYZ 36 359 null]/Next 976 0 R/Parent 704 0 R/Prev 978 0 R/SE 388 0 R/Title(\(C\) If the facility has a surgical residency program and a team of 529 surgical residents start the evaluation and treatment of the trauma patient, the attending surgeon 530 shall participate in all major therapeutic decisions, be present in the emergen\cy department for 531 major resuscitations, and be present during all phases of operative procedures. 532 )>>endobj978 0 obj<</Dest[42 0 R/XYZ 36 372 null]/Next 977 0 R/Parent 704 0 R/Prev 979 0 R/SE 387 0 R/Title( 528 )>>endobj979 0 obj<</Dest[42 0 R/XYZ 36 441 null]/Next 978 0 R/Parent 704 0 R/Prev 980 0 R/SE 386 0 R/Title(\(B\) If a facility has a surgical residency program, and a team of 523 surgical residents start the evaluation and treatment of the trauma patient, the team shall have, at 524 a minimum, a postgraduate year 4 \(PGY-4\) or more senior surgical resident wh\o is a member of 525 the facility•s residency program. The presence of a surgical resident does not take the place of 526 the attending physician. The attending physician must be compliant with all response times. 527 )>>endobj980 0 obj<</Dest[42 0 R/XYZ 36 455 null]/Next 979 0 R/Parent 704 0 R/Prev 981 0 R/SE 385 0 R/Title( 522 )>>endobj981 0 obj<</Dest[42 0 R/XYZ 36 483 null]/Next 980 0 R/Parent 704 0 R/Prev 982 0 R/SE 384 0 R/Title(\(x\) be the admitting physician on all multi-system trauma 520 patients requiring the consultation of one or more specialty services; 521 )>>endobj982 0 obj<</Dest[42 0 R/XYZ 36 497 null]/Next 981 0 R/Parent 704 0 R/Prev 983 0 R/SE 383 0 R/Title( 519 )>>endobj983 0 obj<</Dest[42 0 R/XYZ 36 524 null]/Next 982 0 R/Parent 704 0 R/Prev 984 0 R/SE 382 0 R/Title(\(ix\) be present in the ED within 60 minutes or less when called 517 for a limited trauma team activation; and 518 )>>endobj984 0 obj<</Dest[42 0 R/XYZ 36 538 null]/Next 983 0 R/Parent 704 0 R/Prev 985 0 R/SE 381 0 R/Title( 516 )>>endobj985 0 obj<</Dest[42 0 R/XYZ 36 579 null]/Next 984 0 R/Parent 704 0 R/Prev 986 0 R/SE 380 0 R/Title(\(viii\) be present in the ED at the time of arrival for a full trauma 513 team activation of a trauma patient; maximum response time 30 minutes from trauma team 514 activation; 515 )>>endobj986 0 obj<</Dest[42 0 R/XYZ 36 593 null]/Next 985 0 R/Parent 704 0 R/Prev 987 0 R/SE 379 0 R/Title( 512 )>>endobj987 0 obj<</Dest[42 0 R/XYZ 36 621 null]/Next 986 0 R/Parent 704 0 R/Prev 988 0 R/SE 378 0 R/Title(\(vii\) participate in the trauma QAPI program and attend at least 510 50% of the trauma multidisciplinary and peer review trauma committee meetings; 511 )>>endobj988 0 obj<</Dest[42 0 R/XYZ 36 635 null]/Next 987 0 R/Parent 704 0 R/Prev 989 0 R/SE 377 0 R/Title( 509 )>>endobj989 0 obj<</Dest[42 0 R/XYZ 36 648 null]/Next 988 0 R/Parent 704 0 R/Prev 990 0 R/SE 376 0 R/Title(\(vi\) maintain compliance with trauma protocols; 508 )>>endobj990 0 obj<</Dest[42 0 R/XYZ 36 662 null]/Next 989 0 R/Parent 704 0 R/Prev 991 0 R/SE 375 0 R/Title( 507 )>>endobj991 0 obj<</Dest[42 0 R/XYZ 36 690 null]/Next 990 0 R/Parent 704 0 R/Prev 992 0 R/SE 374 0 R/Title(\(v\) average at least 16 hours of trauma-related continuing 505 medical education annually; 506 )>>endobj992 0 obj<</Dest[42 0 R/XYZ 36 704 null]/Next 991 0 R/Parent 704 0 R/Prev 993 0 R/SE 373 0 R/Title( 504 )>>endobj993 0 obj<</Dest[42 0 R/XYZ 36 717 null]/Next 992 0 R/Parent 704 0 R/Prev 994 0 R/SE 371 0 R/Title(\(iv\) be appropriately credentialed through the trauma program; 503 )>>endobj994 0 obj<</Dest[40 0 R/XYZ 36 96 null]/Next 993 0 R/Parent 704 0 R/Prev 995 0 R/SE 370 0 R/Title( 502 )>>endobj995 0 obj<</Dest[40 0 R/XYZ 36 152 null]/Next 994 0 R/Parent 704 0 R/Prev 996 0 R/SE 369 0 R/Title(\(iii\) prior to \(the effective date of this rule\) have continuously 498 provided trauma coverage and participated in trauma call at the designated facility for the last 499 consecutive five years and be currently credentialed in Advanced Trauma Life Su\pport \(ATLS\); 500 and 501 )>>endobj996 0 obj<</Dest[40 0 R/XYZ 36 165 null]/Next 995 0 R/Parent 704 0 R/Prev 997 0 R/SE 368 0 R/Title( 497 )>>endobj997 0 obj<</Dest[40 0 R/XYZ 36 207 null]/Next 996 0 R/Parent 704 0 R/Prev 998 0 R/SE 367 0 R/Title(\(ii\) be board eligible in general surgery and currently 494 credentialed in Advanced Trauma Life Support \(ATLS\) or an equivalent course approved by the 495 office; or 496 )>>endobj998 0 obj<</Dest[40 0 R/XYZ 36 221 null]/Next 997 0 R/Parent 704 0 R/Prev 999 0 R/SE 366 0 R/Title( 493 )>>endobj999 0 obj<</Dest[40 0 R/XYZ 36 234 null]/Next 998 0 R/Parent 704 0 R/Prev 1000 0 R/SE 365 0 R/Title(\(i\) be board certified in general surgery; or 492 )>>endobj1000 0 obj<</Dest[40 0 R/XYZ 36 248 null]/Next 999 0 R/Parent 704 0 R/Prev 1001 0 R/SE 364 0 R/Title( 491 )>>endobj1001 0 obj<</Dest[40 0 R/XYZ 36 276 null]/Next 1000 0 R/Parent 704 0 R/Prev 1002 0 R/SE 363 0 R/Title(\(A\) All surgeons who provide trauma coverage or participates in 489 trauma call coverage shall: 490 )>>endobj1002 0 obj<</Dest[40 0 R/XYZ 36 290 null]/Next 1001 0 R/Parent 704 0 R/Prev 1003 0 R/SE 362 0 R/Title( 488 )>>endobj1003 0 obj<</Dest[40 0 R/XYZ 36 303 null]/Next 1002 0 R/Parent 704 0 R/Prev 1004 0 R/SE 361 0 R/Title(\(4\) Standard: General Surgery. 487 )>>endobj1004 0 obj<</Dest[40 0 R/XYZ 36 317 null]/Next 1003 0 R/Parent 704 0 R/Prev 1005 0 R/SE 360 0 R/Title( 486 )>>endobj1005 0 obj<</Dest[40 0 R/XYZ 36 359 null]/Next 1004 0 R/Parent 704 0 R/Prev 1006 0 R/SE 359 0 R/Title(\(III\) has continuously served as the Trauma Medical Director at 483 the designated facility for the last consecutive five years and is currently credentialed in 484 Advanced Trauma Life Support \(ATLS\). 485 )>>endobj1006 0 obj<</Dest[40 0 R/XYZ 36 372 null]/Next 1005 0 R/Parent 704 0 R/Prev 1007 0 R/SE 358 0 R/Title( 482 )>>endobj1007 0 obj<</Dest[40 0 R/XYZ 36 414 null]/Next 1006 0 R/Parent 704 0 R/Prev 1008 0 R/SE 357 0 R/Title(\(II\) board certified or board eligible in their applicable medical 479 or surgical specialty and currently credentialed in Advanced Trauma Life Support \(ATLS\) or an 480 equivalent course approved by the office; or 481 )>>endobj1008 0 obj<</Dest[40 0 R/XYZ 36 428 null]/Next 1007 0 R/Parent 704 0 R/Prev 1009 0 R/SE 356 0 R/Title( 478 )>>endobj1009 0 obj<</Dest[40 0 R/XYZ 36 483 null]/Next 1008 0 R/Parent 704 0 R/Prev 1010 0 R/SE 355 0 R/Title(\(I\) board certified in emergency medicine by the American 474 Board of Emergency Medicine \(ABMS or AOBEM\), or eligible for board certification in 475 emergency medicine and currently credentialed in Advanced Trauma Life Support \(ATLS\) or an 476 equi\valent course approved by the office; or 477 )>>endobj1010 0 obj<</Dest[40 0 R/XYZ 36 497 null]/Next 1009 0 R/Parent 704 0 R/Prev 1011 0 R/SE 354 0 R/Title( 473 )>>endobj1011 0 obj<</Dest[40 0 R/XYZ 36 524 null]/Next 1010 0 R/Parent 704 0 R/Prev 1012 0 R/SE 353 0 R/Title(\(v\) The Trauma Medical Director for Level IV shall be a physician 471 who is: 472 )>>endobj1012 0 obj<</Dest[40 0 R/XYZ 36 538 null]/Next 1011 0 R/Parent 704 0 R/Prev 1013 0 R/SE 352 0 R/Title( 470 )>>endobj1013 0 obj<</Dest[40 0 R/XYZ 36 579 null]/Next 1012 0 R/Parent 704 0 R/Prev 1014 0 R/SE 351 0 R/Title(\(II\) a general surgeon who has continuously served as the 467 Trauma Medical Director at the designated facility for the last consecutive five years and is 468 currently credentialed in Advanced Trauma Life Support \(ATLS\). 469 )>>endobj1014 0 obj<</Dest[40 0 R/XYZ 36 593 null]/Next 1013 0 R/Parent 704 0 R/Prev 1015 0 R/SE 350 0 R/Title( 466 )>>endobj1015 0 obj<</Dest[40 0 R/XYZ 36 635 null]/Next 1014 0 R/Parent 704 0 R/Prev 1016 0 R/SE 349 0 R/Title(\(I\) a board certified general surgeon or a general surgeon 463 eligible for certification by the American Board of Surgery according to current requirements or 464 an equivalent course approved by the office; or 465 )>>endobj1016 0 obj<</Dest[40 0 R/XYZ 36 648 null]/Next 1015 0 R/Parent 704 0 R/Prev 1017 0 R/SE 348 0 R/Title( 462 )>>endobj1017 0 obj<</Dest[40 0 R/XYZ 36 676 null]/Next 1016 0 R/Parent 704 0 R/Prev 1018 0 R/SE 347 0 R/Title(\(iv\) The Trauma Medical Director for Level III shall be a physician 460 who is: 461 )>>endobj1018 0 obj<</Dest[40 0 R/XYZ 36 690 null]/Next 1017 0 R/Parent 704 0 R/Prev 1019 0 R/SE 346 0 R/Title( 459 )>>endobj1019 0 obj<</Dest[40 0 R/XYZ 36 717 null]/Next 1018 0 R/Parent 704 0 R/Prev 1020 0 R/SE 344 0 R/Title(\(XIV\) maintains active staff privileges as defined in the 457 facility•s medical staff bylaws; 458 )>>endobj1020 0 obj<</Dest[36 0 R/XYZ 36 110 null]/Next 1019 0 R/Parent 704 0 R/Prev 1021 0 R/SE 343 0 R/Title( 456 )>>endobj1021 0 obj<</Dest[36 0 R/XYZ 36 138 null]/Next 1020 0 R/Parent 704 0 R/Prev 1022 0 R/SE 342 0 R/Title( \(XIII\) averaging 16 hours of continuing trauma medical 454 education \(CME\) annually; 455 )>>endobj1022 0 obj<</Dest[36 0 R/XYZ 36 152 null]/Next 1021 0 R/Parent 704 0 R/Prev 1023 0 R/SE 341 0 R/Title( 453 )>>endobj1023 0 obj<</Dest[36 0 R/XYZ 36 168 null]/Next 1022 0 R/Parent 704 0 R/Prev 1024 0 R/SE 340 0 R/Title( 452 )>>endobj1024 0 obj<</Dest[36 0 R/XYZ 36 193 null]/Next 1023 0 R/Parent 704 0 R/Prev 1025 0 R/SE 339 0 R/Title(\(XII\) evidence that the TMD is aware of the 450 multidisciplinary team findings on all trauma patients; 451 )>>endobj1025 0 obj<</Dest[36 0 R/XYZ 36 207 null]/Next 1024 0 R/Parent 704 0 R/Prev 1026 0 R/SE 338 0 R/Title( 449 )>>endobj1026 0 obj<</Dest[36 0 R/XYZ 36 234 null]/Next 1025 0 R/Parent 704 0 R/Prev 1027 0 R/SE 337 0 R/Title(\(XI\) participates in the facility, community, and regional 447 disaster preparedness activities. 448 )>>endobj1027 0 obj<</Dest[36 0 R/XYZ 36 262 null]/Next 1026 0 R/Parent 704 0 R/Prev 1028 0 R/SE 336 0 R/Title(\(VIX\) participation in the applicable RAC\(s\) and 445 reviewing the RAC trauma system plan. 446 )>>endobj1028 0 obj<</Dest[36 0 R/XYZ 36 276 null]/Next 1027 0 R/Parent 704 0 R/Prev 1029 0 R/SE 335 0 R/Title( 444 )>>endobj1029 0 obj<</Dest[36 0 R/XYZ 36 331 null]/Next 1028 0 R/Parent 704 0 R/Prev 1030 0 R/SE 334 0 R/Title(\(VIII\) ensuring that the trauma quality assessment and 440 performance improvement \(QAPI\)/Multidisciplinary Performance Improvement committee 441 meeting is specific to trauma care, is ongoing, is data driven and effective. TMD serves as chair 442 of \trauma QAPI meetings; 443 )>>endobj1030 0 obj<</Dest[36 0 R/XYZ 36 345 null]/Next 1029 0 R/Parent 704 0 R/Prev 1031 0 R/SE 333 0 R/Title( 439 )>>endobj1031 0 obj<</Dest[36 0 R/XYZ 36 372 null]/Next 1030 0 R/Parent 704 0 R/Prev 1032 0 R/SE 332 0 R/Title(\(VII\) participating in the ongoing education of the 437 medical and nursing staff in the care of the trauma patient; 438 )>>endobj1032 0 obj<</Dest[36 0 R/XYZ 36 386 null]/Next 1031 0 R/Parent 704 0 R/Prev 1033 0 R/SE 331 0 R/Title( 436 )>>endobj1033 0 obj<</Dest[36 0 R/XYZ 36 414 null]/Next 1032 0 R/Parent 704 0 R/Prev 1034 0 R/SE 330 0 R/Title(\(VI\) developing and providing ongoing maintenance of 434 treatment protocols based on current standards of trauma care; 435 )>>endobj1034 0 obj<</Dest[36 0 R/XYZ 36 428 null]/Next 1033 0 R/Parent 704 0 R/Prev 1035 0 R/SE 329 0 R/Title( 433 )>>endobj1035 0 obj<</Dest[36 0 R/XYZ 36 483 null]/Next 1034 0 R/Parent 704 0 R/Prev 1036 0 R/SE 328 0 R/Title(\(V\) ensuring the use of medical staff peer review 429 outcomes, including deviations from trauma standards of care trending, when considering re430 credentialing members of the trauma team. All follow-up and feedback from peer review activity 431 must \be made available to the reviewers at the time of the onsite survey; 432 )>>endobj1036 0 obj<</Dest[36 0 R/XYZ 36 497 null]/Next 1035 0 R/Parent 704 0 R/Prev 1037 0 R/SE 327 0 R/Title( 428 )>>endobj1037 0 obj<</Dest[36 0 R/XYZ 36 524 null]/Next 1036 0 R/Parent 704 0 R/Prev 1038 0 R/SE 326 0 R/Title(\(IV\) has the authority to exclude those trauma team 426 members from trauma call who do not maintain trauma program requirements; 427 )>>endobj1038 0 obj<</Dest[36 0 R/XYZ 36 538 null]/Next 1037 0 R/Parent 704 0 R/Prev 1039 0 R/SE 325 0 R/Title( 425 )>>endobj1039 0 obj<</Dest[36 0 R/XYZ 36 566 null]/Next 1038 0 R/Parent 704 0 R/Prev 1040 0 R/SE 324 0 R/Title(\(III\) regularly and actively participating in or on the 423 trauma call panel; 424 )>>endobj1040 0 obj<</Dest[36 0 R/XYZ 36 579 null]/Next 1039 0 R/Parent 704 0 R/Prev 1041 0 R/SE 323 0 R/Title( 422 )>>endobj1041 0 obj<</Dest[36 0 R/XYZ 36 621 null]/Next 1040 0 R/Parent 704 0 R/Prev 1042 0 R/SE 322 0 R/Title(\(II\) ensuring that a published, on-call schedule and a 419 backup on-call schedule is readily available to all staff in the emergency department for 420 obtaining surgical care for all surgical specialties; 421 )>>endobj1042 0 obj<</Dest[36 0 R/XYZ 36 635 null]/Next 1041 0 R/Parent 704 0 R/Prev 1043 0 R/SE 321 0 R/Title( 418 )>>endobj1043 0 obj<</Dest[36 0 R/XYZ 36 676 null]/Next 1042 0 R/Parent 704 0 R/Prev 1044 0 R/SE 320 0 R/Title(\(I\) reviewing credentials of medical staff requesting 415 privileges on the trauma team and making recommendations to the Medical Executive 416 Committee for either approval or denial of such privileges; 417 )>>endobj1044 0 obj<</Dest[36 0 R/XYZ 36 690 null]/Next 1043 0 R/Parent 704 0 R/Prev 1045 0 R/SE 319 0 R/Title( 414 )>>endobj1045 0 obj<</Dest[36 0 R/XYZ 36 717 null]/Next 1044 0 R/Parent 704 0 R/Prev 1046 0 R/SE 317 0 R/Title(\(iii\) The responsibilities and authority of the Trauma Medical 412 Director shall include but are not limited to: 413 )>>endobj1046 0 obj<</Dest[34 0 R/XYZ 36 96 null]/Next 1045 0 R/Parent 704 0 R/Prev 1047 0 R/SE 316 0 R/Title( 411 )>>endobj1047 0 obj<</Dest[34 0 R/XYZ 36 124 null]/Next 1046 0 R/Parent 704 0 R/Prev 1048 0 R/SE 315 0 R/Title(\(ii\) The Trauma Medical Director shall have responsibility for 409 the overall clinical direction and oversight of the trauma program; 410 )>>endobj1048 0 obj<</Dest[34 0 R/XYZ 36 138 null]/Next 1047 0 R/Parent 704 0 R/Prev 1049 0 R/SE 314 0 R/Title( 408 )>>endobj1049 0 obj<</Dest[34 0 R/XYZ 36 165 null]/Next 1048 0 R/Parent 704 0 R/Prev 1050 0 R/SE 313 0 R/Title(\(i\) The Trauma Medical Director shall be a member of the 406 Medical Executive Committee \(MEC\); 407 )>>endobj1050 0 obj<</Dest[34 0 R/XYZ 36 179 null]/Next 1049 0 R/Parent 704 0 R/Prev 1051 0 R/SE 312 0 R/Title( 405 )>>endobj1051 0 obj<</Dest[34 0 R/XYZ 36 221 null]/Next 1050 0 R/Parent 704 0 R/Prev 1052 0 R/SE 311 0 R/Title(\(A\) Trauma Medical Director. There shall be an identified Trauma 402 Medical Director \(TMD\) responsible for the provision of trauma care and credentialed by the 403 facility for the treatment of trauma patients. 404 )>>endobj1052 0 obj<</Dest[34 0 R/XYZ 36 234 null]/Next 1051 0 R/Parent 704 0 R/Prev 1053 0 R/SE 310 0 R/Title( 401 )>>endobj1053 0 obj<</Dest[34 0 R/XYZ 36 290 null]/Next 1052 0 R/Parent 704 0 R/Prev 1054 0 R/SE 309 0 R/Title(\(3\) Medical Staff. The hospital must have an organized, effective trauma 397 program that is recognized in the medical staff bylaws and approved by the governing body. 398 Medical staff credentialing shall include a process for requesting and granting d\elineation of 399 privileges for trauma care. 400 )>>endobj1054 0 obj<</Dest[34 0 R/XYZ 36 303 null]/Next 1053 0 R/Parent 704 0 R/Prev 1055 0 R/SE 308 0 R/Title( 396 )>>endobj1055 0 obj<</Dest[34 0 R/XYZ 36 331 null]/Next 1054 0 R/Parent 704 0 R/Prev 1056 0 R/SE 307 0 R/Title(\(C\) Daily physician notes by the admitting physician and all sub-394 speciality physicians participating in the patient•s care. 395 )>>endobj1056 0 obj<</Dest[34 0 R/XYZ 36 345 null]/Next 1055 0 R/Parent 704 0 R/Prev 1057 0 R/SE 306 0 R/Title( 393 )>>endobj1057 0 obj<</Dest[34 0 R/XYZ 36 372 null]/Next 1056 0 R/Parent 704 0 R/Prev 1058 0 R/SE 305 0 R/Title(\(B\) Vital signs and other information necessary for ongoing 391 monitoring of the patient•s condition; and 392 )>>endobj1058 0 obj<</Dest[34 0 R/XYZ 36 386 null]/Next 1057 0 R/Parent 704 0 R/Prev 1059 0 R/SE 304 0 R/Title( 390 )>>endobj1059 0 obj<</Dest[34 0 R/XYZ 36 414 null]/Next 1058 0 R/Parent 704 0 R/Prev 1060 0 R/SE 303 0 R/Title(\(A\) Trauma team response times, mechanism of injury, assessments, 388 interventions, and response to interventions; 389 )>>endobj1060 0 obj<</Dest[34 0 R/XYZ 36 428 null]/Next 1059 0 R/Parent 704 0 R/Prev 1061 0 R/SE 302 0 R/Title( 387 )>>endobj1061 0 obj<</Dest[34 0 R/XYZ 36 497 null]/Next 1060 0 R/Parent 704 0 R/Prev 1062 0 R/SE 301 0 R/Title(\(2\) Medical Records Content. Maintain medical records that contain 382 information to justify and support the immediate evaluation, activation, resuscitation, diagnosis, 383 treatment, and describe the patient•s progress and response to medication and \interventions from 384 arrival in the Emergency Department through discharge. Records include evidence of 385 documentation of the following as appropriate: 386 )>>endobj1062 0 obj<</Dest[34 0 R/XYZ 36 510 null]/Next 1061 0 R/Parent 704 0 R/Prev 1063 0 R/SE 300 0 R/Title( 381 )>>endobj1063 0 obj<</Dest[34 0 R/XYZ 36 538 null]/Next 1062 0 R/Parent 704 0 R/Prev 1064 0 R/SE 299 0 R/Title(\(vix\) identify a program sponsor who is a member of the 379 executive leadership at the facility. 380 )>>endobj1064 0 obj<</Dest[34 0 R/XYZ 36 552 null]/Next 1063 0 R/Parent 704 0 R/Prev 1065 0 R/SE 298 0 R/Title( 378 )>>endobj1065 0 obj<</Dest[34 0 R/XYZ 36 593 null]/Next 1064 0 R/Parent 704 0 R/Prev 1066 0 R/SE 297 0 R/Title(\(viii\) contingency plan to ensure the immediate continuation of 375 an active trauma program in the event that the Trauma Medical Director or the Trauma Program 376 Manager position becomes vacant. 377 )>>endobj1066 0 obj<</Dest[34 0 R/XYZ 36 610 null]/Next 1065 0 R/Parent 704 0 R/Prev 1067 0 R/SE 296 0 R/Title( 374 )>>endobj1067 0 obj<</Dest[34 0 R/XYZ 36 648 null]/Next 1066 0 R/Parent 704 0 R/Prev 1068 0 R/SE 295 0 R/Title(\(vii\) shall have a nurse caring for trauma patients as a standing 371 member of the hospital nurse staffing committee as established in accordance with Health and 372 Safety Code \(HSC\), §§161.031 - 161.033; and 373 )>>endobj1068 0 obj<</Dest[34 0 R/XYZ 36 676 null]/Next 1067 0 R/Parent 704 0 R/Prev 1069 0 R/SE 294 0 R/Title(\(vi\) requirements for minimal credentials for staff participating 369 in the care of trauma patients; 370 )>>endobj1069 0 obj<</Dest[34 0 R/XYZ 36 690 null]/Next 1068 0 R/Parent 704 0 R/Prev 1070 0 R/SE 293 0 R/Title( 368 )>>endobj1070 0 obj<</Dest[34 0 R/XYZ 36 717 null]/Next 1069 0 R/Parent 704 0 R/Prev 1071 0 R/SE 291 0 R/Title(\(v\) provisions for participation by the TMD, TPM, TR, or 366 other members of the trauma program in the regional advisory council \(RAC\); 367 )>>endobj1071 0 obj<</Dest[32 0 R/XYZ 36 96 null]/Next 1070 0 R/Parent 704 0 R/Prev 1072 0 R/SE 290 0 R/Title( 365 )>>endobj1072 0 obj<</Dest[32 0 R/XYZ 36 110 null]/Next 1071 0 R/Parent 704 0 R/Prev 1073 0 R/SE 289 0 R/Title(\(iv\) provisions for staff education; and 364 )>>endobj1073 0 obj<</Dest[32 0 R/XYZ 36 124 null]/Next 1072 0 R/Parent 704 0 R/Prev 1074 0 R/SE 288 0 R/Title( 363 )>>endobj1074 0 obj<</Dest[32 0 R/XYZ 36 165 null]/Next 1073 0 R/Parent 704 0 R/Prev 1075 0 R/SE 287 0 R/Title(\(iii\) a quality assurance and performance improvement 360 \(QAPI\)/multidisciplinary PI program to evaluate performance of all trauma care that is hospital 361 wide, ongoing, data driven, and outcomes based; 362 )>>endobj1075 0 obj<</Dest[32 0 R/XYZ 36 179 null]/Next 1074 0 R/Parent 704 0 R/Prev 1076 0 R/SE 286 0 R/Title( 359 )>>endobj1076 0 obj<</Dest[32 0 R/XYZ 36 207 null]/Next 1075 0 R/Parent 704 0 R/Prev 1077 0 R/SE 285 0 R/Title(\(ii\) provisions for ongoing multidisciplinary trauma care 357 meetings and trauma peer review; 358 )>>endobj1077 0 obj<</Dest[32 0 R/XYZ 36 221 null]/Next 1076 0 R/Parent 704 0 R/Prev 1078 0 R/SE 284 0 R/Title( 356 )>>endobj1078 0 obj<</Dest[32 0 R/XYZ 36 331 null]/Next 1077 0 R/Parent 704 0 R/Prev 1079 0 R/SE 283 0 R/Title(\(i\) policies and procedures based on national evidence based 348 practices of trauma care, that are adopted, implemented, and monitored for compliance by the 349 facility that governs the trauma services through all phases of care for all patient popu\lations. 350 The plan shall address the major and severe trauma patient entering into the trauma center and 351 those patients having an ISS of 9 or greater at discharge, telemedicine utilization in the 352 Emergency Department \(ED\), trauma team activat\ions, )>>endobj1079 0 obj<</Dest[32 0 R/XYZ 36 345 null]/Next 1078 0 R/Parent 704 0 R/Prev 1080 0 R/SE 282 0 R/Title( 347 )>>endobj1080 0 obj<</Dest[32 0 R/XYZ 36 359 null]/Next 1079 0 R/Parent 704 0 R/Prev 1081 0 R/SE 281 0 R/Title(\(B\) The written trauma service plan shall include, at a minimum: 346 )>>endobj1081 0 obj<</Dest[32 0 R/XYZ 36 372 null]/Next 1080 0 R/Parent 704 0 R/Prev 1082 0 R/SE 280 0 R/Title( 345 )>>endobj1082 0 obj<</Dest[32 0 R/XYZ 36 414 null]/Next 1081 0 R/Parent 704 0 R/Prev 1083 0 R/SE 279 0 R/Title(\(A\) The written trauma service plan shall be reviewed and approved by 342 the governing body. The governing body shall ensure that the requirements of this chapter are 343 implemented and enforced. 344 )>>endobj1083 0 obj<</Dest[32 0 R/XYZ 36 428 null]/Next 1082 0 R/Parent 704 0 R/Prev 1084 0 R/SE 278 0 R/Title( 341 )>>endobj1084 0 obj<</Dest[32 0 R/XYZ 36 497 null]/Next 1083 0 R/Parent 704 0 R/Prev 1085 0 R/SE 277 0 R/Title(\(1\) Written Plan of Trauma Service Basis and Scope; Levels I-IV. The facility 336 shall develop a written plan of the organized trauma service that includes the scope of services 337 available to all trauma patients, defines the trauma patient populatio\n evaluated or treated by the 338 facility, is consistent with accepted professional standards of practice for trauma care, and 339 ensures the health and safety of patients. 340 )>>endobj1085 0 obj<</Dest[32 0 R/XYZ 36 510 null]/Next 1084 0 R/Parent 704 0 R/Prev 1086 0 R/SE 276 0 R/Title( 335 )>>endobj1086 0 obj<</Dest[32 0 R/XYZ 36 524 null]/Next 1085 0 R/Parent 704 0 R/Prev 1087 0 R/SE 275 0 R/Title(\(i\) Program Requirements. 334 )>>endobj1087 0 obj<</Dest[32 0 R/XYZ 36 538 null]/Next 1086 0 R/Parent 704 0 R/Prev 1088 0 R/SE 274 0 R/Title( 333 )>>endobj1088 0 obj<</Dest[32 0 R/XYZ 36 566 null]/Next 1087 0 R/Parent 704 0 R/Prev 1089 0 R/SE 273 0 R/Title(\(h\) The office may grant an exception to this section if it finds that compliance with 331 this section would not be in the best interests of the persons served in the affected local system. 332 )>>endobj1089 0 obj<</Dest[32 0 R/XYZ 36 579 null]/Next 1088 0 R/Parent 704 0 R/Prev 1090 0 R/SE 272 0 R/Title( 330 )>>endobj1090 0 obj<</Dest[32 0 R/XYZ 36 717 null]/Next 1089 0 R/Parent 704 0 R/Prev 1091 0 R/SE 270 0 R/Title(\(g\) The office shall have the right to review, inspect, evaluate, and audit all trauma 320 patient records, trauma QAPI/performance improvement and peer review committee minutes and 321 other documents relevant to trauma care in any designated trauma fa\cility or applicant/healthcare 322 facility at any time to verify compliance with the statute and this rule, including the designation 323 criteria. The office shall maintain confidentiality of such records to the extent authorized by the 324 Texas Public\ Inf)>>endobj1091 0 obj<</Dest[30 0 R/XYZ 36 110 null]/Next 1090 0 R/Parent 704 0 R/Prev 1092 0 R/SE 269 0 R/Title( 319 )>>endobj1092 0 obj<</Dest[30 0 R/XYZ 36 165 null]/Next 1091 0 R/Parent 704 0 R/Prev 1093 0 R/SE 268 0 R/Title(\(f\) A healthcare facility may not use the terms "trauma facility", "trauma hospital", 315 "trauma center", or similar terminology in its signs, advertisements or in printed materials and 316 information it provides to the public unless the healthcare fa\cility is currently designated as a 317 trauma facility according to the process described in this section. 318 )>>endobj1093 0 obj<</Dest[30 0 R/XYZ 36 179 null]/Next 1092 0 R/Parent 704 0 R/Prev 1094 0 R/SE 267 0 R/Title( 314 )>>endobj1094 0 obj<</Dest[30 0 R/XYZ 36 234 null]/Next 1093 0 R/Parent 704 0 R/Prev 1095 0 R/SE 266 0 R/Title(\(3\) If the facility chooses to relinquish its trauma designation, it shall provide 310 at least 30 day notice to the department, the applicable RAC\(s\), the emergency medical services 311 providers, and healthcare facilities to which it customarily tra\nsfers-out and/or transfers-in 312 trauma patients if it no longer provides trauma services. 313 )>>endobj1095 0 obj<</Dest[30 0 R/XYZ 36 248 null]/Next 1094 0 R/Parent 704 0 R/Prev 1096 0 R/SE 265 0 R/Title( 309 )>>endobj1096 0 obj<</Dest[30 0 R/XYZ 36 276 null]/Next 1095 0 R/Parent 704 0 R/Prev 1097 0 R/SE 264 0 R/Title(\(2\) The facility must notify the office within 5 days of the date that it no 307 longer provides trauma services commensurate with its designation level. 308 )>>endobj1097 0 obj<</Dest[30 0 R/XYZ 36 292 null]/Next 1096 0 R/Parent 704 0 R/Prev 1098 0 R/SE 263 0 R/Title( 306 )>>endobj1098 0 obj<</Dest[30 0 R/XYZ 36 345 null]/Next 1097 0 R/Parent 704 0 R/Prev 1099 0 R/SE 262 0 R/Title(\(1\) A designated trauma facility that is unable to maintain compliance with 302 the level of the current designation may choose to apply for a lower level of trauma designation 303 at any time. It shall be necessary to repeat the designation process for\ the lower level. There shall 304 be a paper review by the office to determine if and when a full survey shall be required. 305 )>>endobj1099 0 obj<</Dest[30 0 R/XYZ 36 359 null]/Next 1098 0 R/Parent 704 0 R/Prev 1100 0 R/SE 261 0 R/Title( 301 )>>endobj1100 0 obj<</Dest[30 0 R/XYZ 36 372 null]/Next 1099 0 R/Parent 704 0 R/Prev 1101 0 R/SE 260 0 R/Title(\(e\) Downgrade of designation levels or relinquishment of designation 300 )>>endobj1101 0 obj<</Dest[30 0 R/XYZ 36 386 null]/Next 1100 0 R/Parent 704 0 R/Prev 1102 0 R/SE 259 0 R/Title( 299 )>>endobj1102 0 obj<</Dest[30 0 R/XYZ 36 414 null]/Next 1101 0 R/Parent 704 0 R/Prev 1103 0 R/SE 258 0 R/Title(\(C\) suspend the facility's designation status or the facility may 297 relinquish designation status. 298 )>>endobj1103 0 obj<</Dest[30 0 R/XYZ 36 428 null]/Next 1102 0 R/Parent 704 0 R/Prev 1104 0 R/SE 257 0 R/Title( 296 )>>endobj1104 0 obj<</Dest[30 0 R/XYZ 36 455 null]/Next 1103 0 R/Parent 704 0 R/Prev 1105 0 R/SE 256 0 R/Title(\(B\) re-designate the facility at the level appropriate to its revised 294 capabilities; or 295 )>>endobj1105 0 obj<</Dest[30 0 R/XYZ 36 469 null]/Next 1104 0 R/Parent 704 0 R/Prev 1106 0 R/SE 255 0 R/Title( 293 )>>endobj1106 0 obj<</Dest[30 0 R/XYZ 36 497 null]/Next 1105 0 R/Parent 704 0 R/Prev 1107 0 R/SE 254 0 R/Title(\(A\) allow the facility to request designation at the level appropriate to 291 its revised capabilities; 292 )>>endobj1107 0 obj<</Dest[30 0 R/XYZ 36 510 null]/Next 1106 0 R/Parent 704 0 R/Prev 1108 0 R/SE 253 0 R/Title( 290 )>>endobj1108 0 obj<</Dest[30 0 R/XYZ 36 607 null]/Next 1107 0 R/Parent 704 0 R/Prev 1109 0 R/SE 252 0 R/Title(\(2\) If the healthcare facility is unable to comply with program requirements to 283 maintain the current designation status, it shall submit to the office a POC as described in \(b\) 284 \(17\) \(A\) \(i … iii\) of this section, and a request for a temp\orary exception to criteria. Any request 285 for an exception shall be submitted in writing from an executive officer of the facility. The office 286 shall review the request and the POC and either grant or deny the exception. If the healthcare 287 facili\ty has not c)>>endobj1109 0 obj<</Dest[30 0 R/XYZ 36 621 null]/Next 1108 0 R/Parent 704 0 R/Prev 1110 0 R/SE 251 0 R/Title( 282 )>>endobj1110 0 obj<</Dest[30 0 R/XYZ 36 690 null]/Next 1109 0 R/Parent 704 0 R/Prev 1111 0 R/SE 250 0 R/Title(\(1\) If a facility is unable to comply with any of the critical elements of the 277 trauma program \(TS, NS, Ortho, TMD, TPM, Anesthesiology, EM, Trauma Registrar, Trauma 278 Registry etc.\), the facility must notify the office, applicable RAC\(s\), the \emergency medical 279 services providers, and the healthcare facilities to which it customarily transfers-out and/or 280 transfers-in trauma patients. 281 )>>endobj1111 0 obj<</Dest[30 0 R/XYZ 36 704 null]/Next 1110 0 R/Parent 704 0 R/Prev 1112 0 R/SE 249 0 R/Title( 276 )>>endobj1112 0 obj<</Dest[30 0 R/XYZ 36 717 null]/Next 1111 0 R/Parent 704 0 R/Prev 1113 0 R/SE 247 0 R/Title(\(d\) Exceptions and Notifications 275 )>>endobj1113 0 obj<</Dest[26 0 R/XYZ 36 97 null]/Next 1112 0 R/Parent 704 0 R/Prev 1114 0 R/SE 246 0 R/Title( 274 )>>endobj1114 0 obj<</Dest[26 0 R/XYZ 36 124 null]/Next 1113 0 R/Parent 704 0 R/Prev 1115 0 R/SE 245 0 R/Title(\(17\) The office shall post the current designation status of each facility on the 272 office website. 273 )>>endobj1115 0 obj<</Dest[26 0 R/XYZ 36 141 null]/Next 1114 0 R/Parent 704 0 R/Prev 1116 0 R/SE 244 0 R/Title( 271 )>>endobj1116 0 obj<</Dest[26 0 R/XYZ 36 166 null]/Next 1115 0 R/Parent 704 0 R/Prev 1117 0 R/SE 243 0 R/Title(\(16\) It shall be necessary to repeat the designation process as described in this 269 section prior to expiration of a facility's designation or the designation expires. 270 )>>endobj1117 0 obj<</Dest[26 0 R/XYZ 36 180 null]/Next 1116 0 R/Parent 704 0 R/Prev 1118 0 R/SE 242 0 R/Title( 268 )>>endobj1118 0 obj<</Dest[26 0 R/XYZ 36 221 null]/Next 1117 0 R/Parent 704 0 R/Prev 1119 0 R/SE 241 0 R/Title(\(15\) Alteration: the trauma designation certificate and the award letter shall not 265 be altered. Any alteration to either document voids trauma designation for the remainder of that 266 cycle. 267 )>>endobj1119 0 obj<</Dest[26 0 R/XYZ 36 235 null]/Next 1118 0 R/Parent 704 0 R/Prev 1120 0 R/SE 240 0 R/Title( 264 )>>endobj1120 0 obj<</Dest[26 0 R/XYZ 36 262 null]/Next 1119 0 R/Parent 704 0 R/Prev 1121 0 R/SE 239 0 R/Title(\(C\) If the facility closes or the trauma designation is revoked or 262 expires, the certificate shall be returned to the department. 263 )>>endobj1121 0 obj<</Dest[26 0 R/XYZ 36 279 null]/Next 1120 0 R/Parent 704 0 R/Prev 1122 0 R/SE 238 0 R/Title( 261 )>>endobj1122 0 obj<</Dest[26 0 R/XYZ 36 304 null]/Next 1121 0 R/Parent 704 0 R/Prev 1123 0 R/SE 237 0 R/Title(\(B\) The trauma designation certificate shall be valid only when 259 displayed with the current letter awarding designation. 260 )>>endobj1123 0 obj<</Dest[26 0 R/XYZ 36 318 null]/Next 1122 0 R/Parent 704 0 R/Prev 1124 0 R/SE 236 0 R/Title( 258 )>>endobj1124 0 obj<</Dest[26 0 R/XYZ 36 373 null]/Next 1123 0 R/Parent 704 0 R/Prev 1125 0 R/SE 235 0 R/Title(\(A\) Display: The hospital shall prominently and conspicuously display 254 the trauma designation certificate and the current letter awarding designation from the 255 Commissioner, in a public area of the licensed premises that is readily visible to pati\ents, 256 employees, and visitors. 257 )>>endobj1125 0 obj<</Dest[26 0 R/XYZ 36 387 null]/Next 1124 0 R/Parent 704 0 R/Prev 1126 0 R/SE 234 0 R/Title( 253 )>>endobj1126 0 obj<</Dest[26 0 R/XYZ 36 414 null]/Next 1125 0 R/Parent 704 0 R/Prev 1127 0 R/SE 233 0 R/Title(\(14\) If the commissioner concurs with the recommendation to designate, the 251 facility shall receive a letter of designation valid for 3 years and a certificate of designation. 252 )>>endobj1127 0 obj<</Dest[26 0 R/XYZ 36 428 null]/Next 1126 0 R/Parent 704 0 R/Prev 1128 0 R/SE 232 0 R/Title( 250 )>>endobj1128 0 obj<</Dest[26 0 R/XYZ 36 455 null]/Next 1127 0 R/Parent 704 0 R/Prev 1129 0 R/SE 231 0 R/Title(\(13\) The facility shall have the right to withdraw its application at any time 248 prior to being recommended for trauma facility designation by the office. 249 )>>endobj1129 0 obj<</Dest[26 0 R/XYZ 36 469 null]/Next 1128 0 R/Parent 704 0 R/Prev 1130 0 R/SE 230 0 R/Title( 247 )>>endobj1130 0 obj<</Dest[26 0 R/XYZ 36 510 null]/Next 1129 0 R/Parent 704 0 R/Prev 1131 0 R/SE 229 0 R/Title(\(11\) The office will review the findings of the survey report and patient care 244 reviews and POC. A recommendation for designation will be made to the commissioner if the 245 facility meets the requirements for designation found in this section. \ 246 )>>endobj1131 0 obj<</Dest[26 0 R/XYZ 36 524 null]/Next 1130 0 R/Parent 704 0 R/Prev 1132 0 R/SE 228 0 R/Title( 243 )>>endobj1132 0 obj<</Dest[26 0 R/XYZ 36 566 null]/Next 1131 0 R/Parent 704 0 R/Prev 1133 0 R/SE 227 0 R/Title(\(10\) If a hospital seeking designation fails to meet the requirements of this 240 section, the application shall be denied and, for facilities seeking redesignation, the original 241 designation will expire on its expiration date. 242 )>>endobj1133 0 obj<</Dest[26 0 R/XYZ 36 579 null]/Next 1132 0 R/Parent 704 0 R/Prev 1134 0 R/SE 226 0 R/Title( 239 )>>endobj1134 0 obj<</Dest[26 0 R/XYZ 36 635 null]/Next 1133 0 R/Parent 704 0 R/Prev 1135 0 R/SE 225 0 R/Title(\(9\) The trauma designation survey report and patient care reviews in its 235 entirety shall be part of the facility's quality assessment and performance improvement 236 \(QAPI\)/Multidisciplinary Trauma PI and peer review program and subject to confiden\tiality as 237 articulated in the Health and Safety Code, §773.095. 238 )>>endobj1135 0 obj<</Dest[26 0 R/XYZ 36 648 null]/Next 1134 0 R/Parent 704 0 R/Prev 1136 0 R/SE 224 0 R/Title( 234 )>>endobj1136 0 obj<</Dest[26 0 R/XYZ 36 717 null]/Next 1135 0 R/Parent 704 0 R/Prev 1137 0 R/SE 222 0 R/Title(\(8\) The surveyor\(s\) shall provide the facility with a written, signed survey 229 report documenting the findings of the facility's compliance / noncompliance with §157.125. 230 The survey report shall be forwarded to the facility within 30 calendar d\ays of the completion 231 date of the survey. The facility is responsible for forwarding a copy of the survey report, 232 including patient record reviews, to the office if it intends to continue the designation process. 233 )>>endobj1137 0 obj<</Dest[24 0 R/XYZ 36 96 null]/Next 1136 0 R/Parent 704 0 R/Prev 1138 0 R/SE 221 0 R/Title( 228 )>>endobj1138 0 obj<</Count 8/Dest[24 0 R/XYZ 36 166 null]/First 1139 0 R/Last 1140 0 R/Next 1137 0 R/Parent 704 0 R/Prev 1141 0 R/SE 212 0 R/Title(\(i\) the Chief Executive Officer 223 )>>endobj1139 0 obj<</Count 1/Dest[24 0 R/XYZ 36 166 null]/First 1276 0 R/Last 1276 0 R/Next 1274 0 R/Parent 1138 0 R/SE 213 0 R/Title(\(i\) the Chief Executive Officer 223 )>>endobj1140 0 obj<</Count 1/Dest[24 0 R/XYZ 36 124 null]/First 1271 0 R/Last 1271 0 R/Parent 1138 0 R/Prev 1272 0 R/SE 219 0 R/Title(\(iv\) the current Executive Sponsor of the trauma program, if not 226 the CEO or CNO. 227 )>>endobj1141 0 obj<</Dest[24 0 R/XYZ 36 179 null]/Next 1138 0 R/Parent 704 0 R/Prev 1142 0 R/SE 211 0 R/Title( 222 )>>endobj1142 0 obj<</Dest[24 0 R/XYZ 36 193 null]/Next 1141 0 R/Parent 704 0 R/Prev 1143 0 R/SE 210 0 R/Title(\(B\) tour of the physical plant; and staff interviews to include: 221 )>>endobj1143 0 obj<</Dest[24 0 R/XYZ 36 221 null]/Next 1142 0 R/Parent 704 0 R/Prev 1144 0 R/SE 209 0 R/Title(\(A\) reviewing documents, including a minimum of 10 closed medical 219 records per surveyor; 220 )>>endobj1144 0 obj<</Dest[24 0 R/XYZ 36 248 null]/Next 1143 0 R/Parent 704 0 R/Prev 1145 0 R/SE 208 0 R/Title(\(7\) The survey team shall evaluate the facility's compliance and document the 217 noncompliance with this section 157.125 by: 218 )>>endobj1145 0 obj<</Dest[24 0 R/XYZ 36 262 null]/Next 1144 0 R/Parent 704 0 R/Prev 1146 0 R/SE 207 0 R/Title( 216 )>>endobj1146 0 obj<</Dest[24 0 R/XYZ 36 290 null]/Next 1145 0 R/Parent 704 0 R/Prev 1147 0 R/SE 206 0 R/Title(\(iii\) have successfully completed a trauma designation surveyor 214 internship. 215 )>>endobj1147 0 obj<</Dest[24 0 R/XYZ 36 303 null]/Next 1146 0 R/Parent 704 0 R/Prev 1148 0 R/SE 205 0 R/Title( 213 )>>endobj1148 0 obj<</Dest[24 0 R/XYZ 36 331 null]/Next 1147 0 R/Parent 704 0 R/Prev 1149 0 R/SE 204 0 R/Title(\(ii\) for physicians: Advanced Trauma Life Support \(ATLS\); 211 and 212 )>>endobj1149 0 obj<</Dest[24 0 R/XYZ 36 345 null]/Next 1148 0 R/Parent 704 0 R/Prev 1150 0 R/SE 203 0 R/Title( 210 )>>endobj1150 0 obj<</Dest[24 0 R/XYZ 36 386 null]/Next 1149 0 R/Parent 704 0 R/Prev 1151 0 R/SE 202 0 R/Title(\(i\) for registered nurses: Trauma Nurses Core Course \(TNCC\) 207 or Advanced Trauma Course for Nurses \(ATCN\); and Pediatric Advanced Life Support \(PALS\) 208 or Emergency Nurses Pediatric Course \(ENPC\); 209 )>>endobj1151 0 obj<</Dest[24 0 R/XYZ 36 400 null]/Next 1150 0 R/Parent 704 0 R/Prev 1152 0 R/SE 201 0 R/Title( 206 )>>endobj1152 0 obj<</Dest[24 0 R/XYZ 36 414 null]/Next 1151 0 R/Parent 704 0 R/Prev 1153 0 R/SE 200 0 R/Title(\(E\) have current credentials as follows: 205 )>>endobj1153 0 obj<</Dest[24 0 R/XYZ 36 428 null]/Next 1152 0 R/Parent 704 0 R/Prev 1154 0 R/SE 199 0 R/Title( 204 )>>endobj1154 0 obj<</Dest[24 0 R/XYZ 36 455 null]/Next 1153 0 R/Parent 704 0 R/Prev 1155 0 R/SE 198 0 R/Title(\(D\) have successfully completed a DSHS-approved trauma facility site 202 surveyor course and be successfully re-credentialed every 4 years; and 203 )>>endobj1155 0 obj<</Dest[24 0 R/XYZ 36 469 null]/Next 1154 0 R/Parent 704 0 R/Prev 1156 0 R/SE 197 0 R/Title( 201 )>>endobj1156 0 obj<</Dest[24 0 R/XYZ 36 497 null]/Next 1155 0 R/Parent 704 0 R/Prev 1157 0 R/SE 196 0 R/Title(\(C\) have direct experience in the preparation for and successful 199 completion of trauma facility designation for no fewer than 2 successful designation cycles; 200 )>>endobj1157 0 obj<</Dest[24 0 R/XYZ 36 510 null]/Next 1156 0 R/Parent 704 0 R/Prev 1158 0 R/SE 195 0 R/Title( 198 )>>endobj1158 0 obj<</Dest[24 0 R/XYZ 36 538 null]/Next 1157 0 R/Parent 704 0 R/Prev 1159 0 R/SE 194 0 R/Title(\(B\) be currently employed in the management of or providing direct 196 care services to trauma patients; 197 )>>endobj1159 0 obj<</Dest[24 0 R/XYZ 36 552 null]/Next 1158 0 R/Parent 704 0 R/Prev 1160 0 R/SE 193 0 R/Title( 195 )>>endobj1160 0 obj<</Dest[24 0 R/XYZ 36 566 null]/Next 1159 0 R/Parent 704 0 R/Prev 1161 0 R/SE 192 0 R/Title(\(A\) have at least 5 years experience in the care of trauma patients; 194 )>>endobj1161 0 obj<</Dest[24 0 R/XYZ 36 579 null]/Next 1160 0 R/Parent 704 0 R/Prev 1162 0 R/SE 191 0 R/Title( 193 )>>endobj1162 0 obj<</Dest[24 0 R/XYZ 36 593 null]/Next 1161 0 R/Parent 704 0 R/Prev 1163 0 R/SE 190 0 R/Title(\(6\) Each member of the survey team shall: 192 )>>endobj1163 0 obj<</Dest[24 0 R/XYZ 36 607 null]/Next 1162 0 R/Parent 704 0 R/Prev 1164 0 R/SE 189 0 R/Title( 191 )>>endobj1164 0 obj<</Dest[24 0 R/XYZ 36 635 null]/Next 1163 0 R/Parent 704 0 R/Prev 1165 0 R/SE 188 0 R/Title(\(vii\) not possess other potential conflict of interest between the 189 surveyor or the surveyor's place of employment and the facility being surveyed. 190 )>>endobj1165 0 obj<</Dest[24 0 R/XYZ 36 648 null]/Next 1164 0 R/Parent 704 0 R/Prev 1166 0 R/SE 187 0 R/Title( 188 )>>endobj1166 0 obj<</Dest[24 0 R/XYZ 36 662 null]/Next 1165 0 R/Parent 704 0 R/Prev 1167 0 R/SE 186 0 R/Title(\(vi\) not have been requested by the facility; 187 )>>endobj1167 0 obj<</Dest[24 0 R/XYZ 36 676 null]/Next 1166 0 R/Parent 704 0 R/Prev 1168 0 R/SE 185 0 R/Title( 186 )>>endobj1168 0 obj<</Dest[24 0 R/XYZ 36 704 null]/Next 1167 0 R/Parent 704 0 R/Prev 1169 0 R/SE 184 0 R/Title(\(v\) not survey the facility program and physical location on 184 consecutive designation cycles; and 185 )>>endobj1169 0 obj<</Dest[24 0 R/XYZ 36 717 null]/Next 1168 0 R/Parent 704 0 R/Prev 1170 0 R/SE 182 0 R/Title( 183 )>>endobj1170 0 obj<</Dest[22 0 R/XYZ 36 110 null]/Next 1169 0 R/Parent 704 0 R/Prev 1171 0 R/SE 181 0 R/Title(\(iv\) not be employed at a facility that is a primary transfer 181 facility with the facility being surveyed, with the exception of a burn facility; 182 )>>endobj1171 0 obj<</Dest[22 0 R/XYZ 36 124 null]/Next 1170 0 R/Parent 704 0 R/Prev 1172 0 R/SE 180 0 R/Title( 180 )>>endobj1172 0 obj<</Dest[22 0 R/XYZ 36 152 null]/Next 1171 0 R/Parent 704 0 R/Prev 1173 0 R/SE 179 0 R/Title(\(iii\) not be a current or former employee of the facility that is 178 the subject of the survey or of an affiliated facility; 179 )>>endobj1173 0 obj<</Dest[22 0 R/XYZ 36 165 null]/Next 1172 0 R/Parent 704 0 R/Prev 1174 0 R/SE 178 0 R/Title( 177 )>>endobj1174 0 obj<</Dest[22 0 R/XYZ 36 193 null]/Next 1173 0 R/Parent 704 0 R/Prev 1175 0 R/SE 177 0 R/Title(\(ii\) not be employed in the same TSA as the designating 175 facility; 176 )>>endobj1175 0 obj<</Dest[22 0 R/XYZ 36 207 null]/Next 1174 0 R/Parent 704 0 R/Prev 1176 0 R/SE 176 0 R/Title( 174 )>>endobj1176 0 obj<</Dest[22 0 R/XYZ 36 234 null]/Next 1175 0 R/Parent 704 0 R/Prev 1177 0 R/SE 175 0 R/Title(\(i\) be currently employed at a designated trauma facility that is 172 greater than 100 miles from the requesting facility; 173 )>>endobj1177 0 obj<</Dest[22 0 R/XYZ 36 248 null]/Next 1176 0 R/Parent 704 0 R/Prev 1178 0 R/SE 174 0 R/Title( 171 )>>endobj1178 0 obj<</Dest[22 0 R/XYZ 36 262 null]/Next 1177 0 R/Parent 704 0 R/Prev 1179 0 R/SE 173 0 R/Title(\(D\) Each member of the survey teams described above shall: 170 )>>endobj1179 0 obj<</Dest[22 0 R/XYZ 36 276 null]/Next 1178 0 R/Parent 704 0 R/Prev 1180 0 R/SE 172 0 R/Title( 169 )>>endobj1180 0 obj<</Dest[22 0 R/XYZ 36 372 null]/Next 1179 0 R/Parent 704 0 R/Prev 1181 0 R/SE 171 0 R/Title(\(C\) Level IV facilities shall be surveyed by an office approved 162 organization by a surveyor that is either at a minimum: a registered nurse or a licensed physician, 163 active in the management of trauma patients. Children•s facilities shall be surve\yed by an office-164 approved organization, whose surveyor is a general surgeon with pediatric experience, or a 165 pediatric trauma nurse, or a Trauma Program Manager with pediatric experience, active in the 166 management of pediatric trauma patients. A\ sec)>>endobj1181 0 obj<</Dest[22 0 R/XYZ 36 386 null]/Next 1180 0 R/Parent 704 0 R/Prev 1182 0 R/SE 170 0 R/Title( 161 )>>endobj1182 0 obj<</Dest[22 0 R/XYZ 36 497 null]/Next 1181 0 R/Parent 704 0 R/Prev 1183 0 R/SE 169 0 R/Title(\(B\) Level III facilities shall be surveyed by the ACS, or other office-153 approved organization, with a multi-disciplinary team that includes at a minimum: a trauma 154 surgeon and a trauma nurse, active in the management of trauma patients. Pediatric \facilities 155 shall be surveyed by the ACS, or an office-approved organization with a multi-disciplinary team 156 that includes at a minimum: a trauma surgeon with pediatric experience, and a pediatric trauma 157 nurse or a Trauma Program Manager with pe\diat)>>endobj1183 0 obj<</Dest[22 0 R/XYZ 36 510 null]/Next 1182 0 R/Parent 704 0 R/Prev 1184 0 R/SE 168 0 R/Title( 152 )>>endobj1184 0 obj<</Dest[22 0 R/XYZ 36 593 null]/Next 1183 0 R/Parent 704 0 R/Prev 1185 0 R/SE 167 0 R/Title(\(A\) Level I or Level II facilities shall be surveyed by The American 146 College of Surgeons \(ACS\) with a multi-disciplinary team and includes at a minimum: two 147 trauma surgeons, and a trauma nurse all active in the management of trauma patients. P\ediatric 148 facilities shall be surveyed by the ACS with a multi-disciplinary team and includes at a 149 minimum: one pediatric trauma surgeon; one adult trauma surgeon, and a pediatric trauma 150 nurse, all active in the management of trauma patients. \ 151 )>>endobj1185 0 obj<</Dest[22 0 R/XYZ 36 607 null]/Next 1184 0 R/Parent 704 0 R/Prev 1186 0 R/SE 166 0 R/Title( 145 )>>endobj1186 0 obj<</Dest[22 0 R/XYZ 36 635 null]/Next 1185 0 R/Parent 704 0 R/Prev 1187 0 R/SE 165 0 R/Title(\(3\) The multi-disciplinary survey team shall consist of the following 143 members: 144 )>>endobj1187 0 obj<</Dest[22 0 R/XYZ 36 648 null]/Next 1186 0 R/Parent 704 0 R/Prev 1188 0 R/SE 164 0 R/Title( 142 )>>endobj1188 0 obj<</Dest[22 0 R/XYZ 36 676 null]/Next 1187 0 R/Parent 704 0 R/Prev 1189 0 R/SE 163 0 R/Title(\(B\) The office, at its discretion, may appoint an observer to accompany 140 the survey team. In this event, the cost for the observer shall be borne by the office. 141 )>>endobj1189 0 obj<</Dest[22 0 R/XYZ 36 690 null]/Next 1188 0 R/Parent 704 0 R/Prev 1190 0 R/SE 162 0 R/Title( 139 )>>endobj1190 0 obj<</Dest[22 0 R/XYZ 36 717 null]/Next 1189 0 R/Parent 704 0 R/Prev 1191 0 R/SE 160 0 R/Title(\(A\) The facility shall be responsible for any expenses associated with 137 the survey. 138 )>>endobj1191 0 obj<</Dest[15 0 R/XYZ 36 110 null]/Next 1190 0 R/Parent 704 0 R/Prev 1192 0 R/SE 159 0 R/Title( 136 )>>endobj1192 0 obj<</Dest[15 0 R/XYZ 36 138 null]/Next 1191 0 R/Parent 704 0 R/Prev 1193 0 R/SE 158 0 R/Title(\(2\) The surveying organization shall notify the office of the date of the 134 scheduled survey and shall schedule the members of the survey team. 135 )>>endobj1193 0 obj<</Dest[15 0 R/XYZ 36 152 null]/Next 1192 0 R/Parent 704 0 R/Prev 1194 0 R/SE 157 0 R/Title( 133 )>>endobj1194 0 obj<</Dest[15 0 R/XYZ 36 179 null]/Next 1193 0 R/Parent 704 0 R/Prev 1195 0 R/SE 156 0 R/Title(\(C\) Level IV facilities shall request a trauma designation survey 131 through an organization approved by the office. 132 )>>endobj1195 0 obj<</Dest[15 0 R/XYZ 36 193 null]/Next 1194 0 R/Parent 704 0 R/Prev 1196 0 R/SE 155 0 R/Title( 130 )>>endobj1196 0 obj<</Dest[15 0 R/XYZ 36 234 null]/Next 1195 0 R/Parent 704 0 R/Prev 1197 0 R/SE 154 0 R/Title(\(B\) Level III facilities shall request a trauma verification survey 127 through the ACS trauma verification program, or request a trauma designation survey through an 128 organization approved by the office; and 129 )>>endobj1197 0 obj<</Dest[15 0 R/XYZ 36 248 null]/Next 1196 0 R/Parent 704 0 R/Prev 1198 0 R/SE 153 0 R/Title( 126 )>>endobj1198 0 obj<</Dest[15 0 R/XYZ 36 276 null]/Next 1197 0 R/Parent 704 0 R/Prev 1199 0 R/SE 152 0 R/Title(\(A\) Level I and II facilities shall request a trauma verification survey 124 through the American College of Surgeons \(ACS\) trauma verification program; 125 )>>endobj1199 0 obj<</Dest[15 0 R/XYZ 36 290 null]/Next 1198 0 R/Parent 704 0 R/Prev 1200 0 R/SE 151 0 R/Title( 123 )>>endobj1200 0 obj<</Dest[15 0 R/XYZ 36 317 null]/Next 1199 0 R/Parent 704 0 R/Prev 1201 0 R/SE 150 0 R/Title(\(1\) The facility shall be responsible for scheduling a verification or trauma 121 designation survey as follows: 122 )>>endobj1201 0 obj<</Dest[15 0 R/XYZ 36 331 null]/Next 1200 0 R/Parent 704 0 R/Prev 1202 0 R/SE 149 0 R/Title( 120 )>>endobj1202 0 obj<</Dest[15 0 R/XYZ 36 359 null]/Next 1201 0 R/Parent 704 0 R/Prev 1203 0 R/SE 148 0 R/Title(\(c\) Survey Process. A facility seeking designation shall undergo an onsite survey 118 as outlined in this section. 119 )>>endobj1203 0 obj<</Dest[15 0 R/XYZ 36 372 null]/Next 1202 0 R/Parent 704 0 R/Prev 1204 0 R/SE 147 0 R/Title( 117 )>>endobj1204 0 obj<</Dest[15 0 R/XYZ 36 400 null]/Next 1203 0 R/Parent 704 0 R/Prev 1205 0 R/SE 146 0 R/Title(\(I\) If a facility seeking designation fails to meet the requirements in 115 subsection \(c\)\(1\) … \(5\) above, the application shall be considered withdrawn by the facility. 116 )>>endobj1205 0 obj<</Dest[15 0 R/XYZ 36 414 null]/Next 1204 0 R/Parent 704 0 R/Prev 1206 0 R/SE 145 0 R/Title( 114 )>>endobj1206 0 obj<</Dest[15 0 R/XYZ 36 455 null]/Next 1205 0 R/Parent 704 0 R/Prev 1207 0 R/SE 144 0 R/Title(\(H\) Renewal of designation. The applicant shall submit the documents 111 described in subsection \(bc\)\(1\) \(C\) … \(G5\) above, to the office at least 90 days prior to the 112 designation expiration date. 113 )>>endobj1207 0 obj<</Dest[15 0 R/XYZ 36 469 null]/Next 1206 0 R/Parent 704 0 R/Prev 1208 0 R/SE 143 0 R/Title( 110 )>>endobj1208 0 obj<</Dest[15 0 R/XYZ 36 483 null]/Next 1207 0 R/Parent 704 0 R/Prev 1209 0 R/SE 142 0 R/Title(\(G\) evidence of submission of data to the department trauma registry 109 )>>endobj1209 0 obj<</Dest[15 0 R/XYZ 36 497 null]/Next 1208 0 R/Parent 704 0 R/Prev 1210 0 R/SE 141 0 R/Title( 108 )>>endobj1210 0 obj<</Dest[15 0 R/XYZ 36 524 null]/Next 1209 0 R/Parent 704 0 R/Prev 1211 0 R/SE 140 0 R/Title(\(F\) evidence of participation in the applicable Regional Advisory 106 Council \(RAC\). 107 )>>endobj1211 0 obj<</Dest[15 0 R/XYZ 36 538 null]/Next 1210 0 R/Parent 704 0 R/Prev 1212 0 R/SE 139 0 R/Title( 105 )>>endobj1212 0 obj<</Dest[15 0 R/XYZ 36 621 null]/Next 1211 0 R/Parent 704 0 R/Prev 1213 0 R/SE 138 0 R/Title(\(E\) a plan of correction \(POC\), detailing how the facility will correct 99 any deficiencies cited in the survey report, to include: statement of the cited deficiency, the 100 corrective action to ensure compliance with the requirement, the title of th\e individual\(s\) 101 responsible for ensuring the correction action\(s\) is implemented, the date by which the corrective 102 action will be implemented, not to exceed 90 days from the date the facility received the official 103 survey report, and how th\e correcti)>>endobj1213 0 obj<</Dest[15 0 R/XYZ 42 635 null]/Next 1212 0 R/Parent 704 0 R/Prev 1214 0 R/SE 137 0 R/Title( 98 )>>endobj1214 0 obj<</Dest[15 0 R/XYZ 42 676 null]/Next 1213 0 R/Parent 704 0 R/Prev 1215 0 R/SE 136 0 R/Title(\(D\) a completed trauma designation survey report, including patient 95 care reviews, if required by the department, submitted no later than 180 days from the date of the 96 survey; 97 )>>endobj1215 0 obj<</Dest[15 0 R/XYZ 42 690 null]/Next 1214 0 R/Parent 704 0 R/Prev 1216 0 R/SE 135 0 R/Title( 94 )>>endobj1216 0 obj<</Dest[15 0 R/XYZ 42 717 null]/Next 1215 0 R/Parent 704 0 R/Prev 1217 0 R/SE 133 0 R/Title(\(C\) any subsequent documents submitted by the date requested by the 92 office; 93 )>>endobj1217 0 obj<</Dest[13 0 R/XYZ 42 110 null]/Next 1216 0 R/Parent 704 0 R/Prev 1218 0 R/SE 132 0 R/Title( 91 )>>endobj1218 0 obj<</Dest[13 0 R/XYZ 42 193 null]/Next 1217 0 R/Parent 704 0 R/Prev 1219 0 R/SE 131 0 R/Title(\(B\) Initial designation of a trauma facility. The CEO, TMD and TPM 85 of the facility shall attend a presurvey conference at the office designated by the department. The 86 purpose of the presurvey conference, conducted by department staff, is to review\ and discuss the 87 designation requirements for the applicable level prior to the initial onsite designation survey. 88 The department may waive the presurvey conference requirement. A facility will not be 89 recommended for designation until the presur\vey )>>endobj1219 0 obj<</Dest[13 0 R/XYZ 42 207 null]/Next 1218 0 R/Parent 704 0 R/Prev 1220 0 R/SE 130 0 R/Title( 84 )>>endobj1220 0 obj<</Dest[13 0 R/XYZ 42 234 null]/Next 1219 0 R/Parent 704 0 R/Prev 1221 0 R/SE 129 0 R/Title(\(iii\) Level IV trauma facility applicants, the fee will be no more 82 than $10 per licensed bed with an upper limit of $1000 and a lower limit of $500. 83 )>>endobj1221 0 obj<</Dest[13 0 R/XYZ 42 248 null]/Next 1220 0 R/Parent 704 0 R/Prev 1222 0 R/SE 128 0 R/Title( 81 )>>endobj1222 0 obj<</Dest[13 0 R/XYZ 42 276 null]/Next 1221 0 R/Parent 704 0 R/Prev 1223 0 R/SE 127 0 R/Title(\(ii\) Level III trauma facility applicants, the fee will be no more 79 than $10 per licensed bed with an upper limit of $2,500 and a lower limit of $1,500; and 80 )>>endobj1223 0 obj<</Dest[13 0 R/XYZ 42 290 null]/Next 1222 0 R/Parent 704 0 R/Prev 1224 0 R/SE 126 0 R/Title( 78 )>>endobj1224 0 obj<</Dest[13 0 R/XYZ 42 317 null]/Next 1223 0 R/Parent 704 0 R/Prev 1225 0 R/SE 125 0 R/Title(\(i\) Level I and Level II trauma facility applicants, the fee will 76 be no more than $10 per licensed bed with an upper limit of $5,000 and a lower limit of $4,000; 77 )>>endobj1225 0 obj<</Dest[13 0 R/XYZ 42 331 null]/Next 1224 0 R/Parent 704 0 R/Prev 1226 0 R/SE 124 0 R/Title( 75 )>>endobj1226 0 obj<</Dest[13 0 R/XYZ 42 372 null]/Next 1225 0 R/Parent 704 0 R/Prev 1227 0 R/SE 123 0 R/Title(\(A\) an accurate and complete designation application form for the 72 appropriate level of requested designation, including full payment of the non-refundable, non-73 transferrable, designation fee as follows; 74 )>>endobj1227 0 obj<</Dest[13 0 R/XYZ 42 386 null]/Next 1226 0 R/Parent 704 0 R/Prev 1228 0 R/SE 122 0 R/Title( 71 )>>endobj1228 0 obj<</Dest[13 0 R/XYZ 42 414 null]/Next 1227 0 R/Parent 704 0 R/Prev 1229 0 R/SE 121 0 R/Title(\(1\) Application. A facility seeking designation, shall submit a completed 69 application to include: 70 )>>endobj1229 0 obj<</Dest[13 0 R/XYZ 42 428 null]/Next 1228 0 R/Parent 704 0 R/Prev 1230 0 R/SE 120 0 R/Title( 68 )>>endobj1230 0 obj<</Dest[13 0 R/XYZ 42 441 null]/Next 1229 0 R/Parent 704 0 R/Prev 1231 0 R/SE 119 0 R/Title(\(b\) Designation Process. 67 )>>endobj1231 0 obj<</Dest[13 0 R/XYZ 42 455 null]/Next 1230 0 R/Parent 704 0 R/Prev 1232 0 R/SE 118 0 R/Title( 66 )>>endobj1232 0 obj<</Dest[13 0 R/XYZ 42 497 null]/Next 1231 0 R/Parent 704 0 R/Prev 1233 0 R/SE 117 0 R/Title( \(6\) In Active Pursuit of Designation \(IAP\). Subsection applies only to an 63 undesignated facility in accordance with Texas Administrative Code \(TAC\) Designated Trauma 64 Facility and Emergency Medical Services Account Section 157.131\(a\)\(10\).\ 65 )>>endobj1233 0 obj<</Dest[13 0 R/XYZ 42 510 null]/Next 1232 0 R/Parent 704 0 R/Prev 1234 0 R/SE 116 0 R/Title( 62 )>>endobj1234 0 obj<</Dest[13 0 R/XYZ 42 538 null]/Next 1233 0 R/Parent 704 0 R/Prev 1235 0 R/SE 115 0 R/Title(\(D\) Basic \(Level IV\) trauma facility designation. The facility meets 60 the Level IV Program Requirements in subsection \(k\) of this section. 61 )>>endobj1235 0 obj<</Dest[13 0 R/XYZ 42 552 null]/Next 1234 0 R/Parent 704 0 R/Prev 1236 0 R/SE 114 0 R/Title( 59 )>>endobj1236 0 obj<</Dest[13 0 R/XYZ 42 607 null]/Next 1235 0 R/Parent 704 0 R/Prev 1237 0 R/SE 113 0 R/Title(\(C\) Advanced \(Level III\) trauma facility designation. The facility shall 55 meet the Level III Program Requirements in subsection \(k\) of this section and if the facility 56 chooses to be verified by the ACS the facility must meet the current ACS es\sential criteria for a 57 verified Level III trauma center. 58 )>>endobj1237 0 obj<</Dest[13 0 R/XYZ 42 621 null]/Next 1236 0 R/Parent 704 0 R/Prev 1238 0 R/SE 112 0 R/Title( 54 )>>endobj1238 0 obj<</Dest[13 0 R/XYZ 42 648 null]/Next 1237 0 R/Parent 704 0 R/Prev 1239 0 R/SE 111 0 R/Title(\(B\) Major \(Level II\) trauma facility designation. The facility shall 52 meet the current ACS essential criteria for a verified Level II trauma center. 53 )>>endobj1239 0 obj<</Dest[13 0 R/XYZ 42 662 null]/Next 1238 0 R/Parent 704 0 R/Prev 1240 0 R/SE 110 0 R/Title( 51 )>>endobj1240 0 obj<</Dest[13 0 R/XYZ 42 704 null]/Next 1239 0 R/Parent 704 0 R/Prev 1241 0 R/SE 109 0 R/Title(\(A\) Comprehensive \(Level I\) trauma facility designation. The facility 48 shall meet the current American College of Surgeons \(ACS\) essential criteria for a verified Level 49 I trauma center. 50 )>>endobj1241 0 obj<</Dest[13 0 R/XYZ 42 717 null]/Next 1240 0 R/Parent 704 0 R/Prev 1242 0 R/SE 107 0 R/Title( 47 )>>endobj1242 0 obj<</Dest[3 0 R/XYZ 42 110 null]/Next 1241 0 R/Parent 704 0 R/Prev 1243 0 R/SE 106 0 R/Title(\(5\) The four levels of trauma designation and the requirements for each are as 45 follows: 46 )>>endobj1243 0 obj<</Dest[3 0 R/XYZ 42 124 null]/Next 1242 0 R/Parent 704 0 R/Prev 1244 0 R/SE 105 0 R/Title( 44 )>>endobj1244 0 obj<</Dest[3 0 R/XYZ 42 179 null]/Next 1243 0 R/Parent 704 0 R/Prev 1245 0 R/SE 104 0 R/Title(\(4\) a trauma facility designation is issued for the physical location and to the 40 legal owner of the operations of the facility. If a designated facility has a change of ownership or 41 a change of the physical location of the facility, the designatio\n shall not be transferred or 42 assigned. 43 )>>endobj1245 0 obj<</Dest[3 0 R/XYZ 42 193 null]/Next 1244 0 R/Parent 704 0 R/Prev 1246 0 R/SE 103 0 R/Title( 39 )>>endobj1246 0 obj<</Dest[3 0 R/XYZ 42 221 null]/Next 1245 0 R/Parent 704 0 R/Prev 1247 0 R/SE 102 0 R/Title(\(iii\) Departments or services within a facility shall not be 37 separately designated. 38 )>>endobj1247 0 obj<</Dest[3 0 R/XYZ 42 234 null]/Next 1246 0 R/Parent 704 0 R/Prev 1248 0 R/SE 101 0 R/Title( 36 )>>endobj1248 0 obj<</Count 4/Dest[3 0 R/XYZ 42 318 null]/First 1249 0 R/Last 1250 0 R/Next 1247 0 R/Parent 704 0 R/Prev 1251 0 R/SE 96 0 R/Title(\(i\) Each facility operating on a single general hospital license 30 with multiple locations \(multi-location license\) shall be 31 considered separately for designation. 32 )>>endobj1249 0 obj<</Count 1/Dest[3 0 R/XYZ 42 318 null]/First 1270 0 R/Last 1270 0 R/Next 1250 0 R/Parent 1248 0 R/SE 97 0 R/Title(\(i\) Each facility operating on a single general hospital license 30 with multiple locations \(multi-location license\) shall be 31 considered separately for designation. 32 )>>endobj1250 0 obj<</Count 1/Dest[3 0 R/XYZ 42 276 null]/First 1269 0 R/Last 1269 0 R/Parent 1248 0 R/Prev 1249 0 R/SE 99 0 R/Title(\(ii\) Designation does not include provider based departments 33 of the designated facility, which are not contiguous with the 34 designated facility. 35 )>>endobj1251 0 obj<</Dest[3 0 R/XYZ 42 334 null]/Next 1248 0 R/Parent 704 0 R/Prev 1252 0 R/SE 95 0 R/Title( 29 )>>endobj1252 0 obj<</Dest[3 0 R/XYZ 42 348 null]/Next 1251 0 R/Parent 704 0 R/Prev 1253 0 R/SE 94 0 R/Title(\(C\) a general hospital owned and operated by the federal government. 28 )>>endobj1253 0 obj<</Dest[3 0 R/XYZ 42 359 null]/Next 1252 0 R/Parent 704 0 R/Prev 1254 0 R/SE 93 0 R/Title( 27 )>>endobj1254 0 obj<</Dest[3 0 R/XYZ 42 372 null]/Next 1253 0 R/Parent 704 0 R/Prev 1255 0 R/SE 92 0 R/Title(\(B\) a general hospital owned and operated by the state of Texas, or 26 )>>endobj1255 0 obj<</Dest[3 0 R/XYZ 42 386 null]/Next 1254 0 R/Parent 704 0 R/Prev 1256 0 R/SE 91 0 R/Title( 25 )>>endobj1256 0 obj<</Dest[3 0 R/XYZ 42 400 null]/Next 1255 0 R/Parent 704 0 R/Prev 1257 0 R/SE 90 0 R/Title( 24 )>>endobj1257 0 obj<</Dest[3 0 R/XYZ 42 428 null]/Next 1256 0 R/Parent 704 0 R/Prev 1258 0 R/SE 89 0 R/Title(\(A\) A General Hospital, licensed or otherwise meeting the description 22 \(in accordance with Texas Administrative Code \(TAC\) Hospital Licensing Section 133.21\). 23 )>>endobj1258 0 obj<</Dest[3 0 R/XYZ 42 441 null]/Next 1257 0 R/Parent 704 0 R/Prev 1259 0 R/SE 88 0 R/Title( 21 )>>endobj1259 0 obj<</Dest[3 0 R/XYZ 42 455 null]/Next 1258 0 R/Parent 704 0 R/Prev 1260 0 R/SE 87 0 R/Title(\(3\) Facilities eligible for trauma designation include: 20 )>>endobj1260 0 obj<</Dest[3 0 R/XYZ 42 469 null]/Next 1259 0 R/Parent 704 0 R/Prev 1261 0 R/SE 86 0 R/Title( 19 )>>endobj1261 0 obj<</Dest[3 0 R/XYZ 42 524 null]/Next 1260 0 R/Parent 704 0 R/Prev 1262 0 R/SE 85 0 R/Title(\(2\) The Office of Emergency Medical Services \(EMS\)/Trauma Systems 15 Coordination \(office\) shall recommend to the Commissioner of the Department of State Health 16 Services \(commissioner\) the trauma designation of a facility at the level the offic\e deems 17 appropriate. 18 )>>endobj1262 0 obj<</Dest[3 0 R/XYZ 42 538 null]/Next 1261 0 R/Parent 704 0 R/Prev 1263 0 R/SE 84 0 R/Title( 14 )>>endobj1263 0 obj<</Dest[3 0 R/XYZ 42 593 null]/Next 1262 0 R/Parent 704 0 R/Prev 1264 0 R/SE 83 0 R/Title(\(1\) The Department of State Health Services \(department\) shall determine the 10 designation level for each location, based on, but not limited to, the location's own resources and 11 levels of care capabilities; Trauma Service Area \(TSA\) capabilitie\s; and compliance with the 12 essential criteria and standard requirements outlined in this section. 13 )>>endobj1264 0 obj<</Dest[3 0 R/XYZ 48 607 null]/Next 1263 0 R/Parent 704 0 R/Prev 1265 0 R/SE 82 0 R/Title( 9 )>>endobj1265 0 obj<</Dest[3 0 R/XYZ 48 662 null]/Next 1264 0 R/Parent 704 0 R/Prev 1266 0 R/SE 81 0 R/Title(\(a\) General Provisions. The goal of the trauma system is to reduce the morbidity and 5 mortality of the trauma patient. The objective of the trauma system is to get the right patient, to 6 the right place, at the right time, to receive the right care. T\he purpose of this section is to set 7 forth the requirements for a health care facility to become a designated trauma facility. 8 )>>endobj1266 0 obj<</Dest[3 0 R/XYZ 48 676 null]/Next 1265 0 R/Parent 704 0 R/Prev 1267 0 R/SE 80 0 R/Title( 4 )>>endobj1267 0 obj<</Dest[3 0 R/XYZ 48 690 null]/Next 1266 0 R/Parent 704 0 R/Prev 1268 0 R/SE 79 0 R/Title(§157.125. Requirements for Trauma Facility Designation. 3 )>>endobj1268 0 obj<</Dest[3 0 R/XYZ 48 704 null]/Next 1267 0 R/Parent 704 0 R/Prev 705 0 R/SE 78 0 R/Title( 2 )>>endobj1269 0 obj<</Dest[3 0 R/XYZ 42 276 null]/Parent 1250 0 R/SE 100 0 R/Title(\(ii\) Designation does not include provider based departments 33 of the designated facility, which are not contiguous with the 34 designated facility. 35 )>>endobj1270 0 obj<</Dest[3 0 R/XYZ 42 318 null]/Parent 1249 0 R/SE 98 0 R/Title(\(i\) Each facility operating on a single general hospital license 30 with multiple locations \(multi-location license\) shall be 31 considered separately for designation. 32 )>>endobj1271 0 obj<</Dest[24 0 R/XYZ 36 124 null]/Parent 1140 0 R/SE 220 0 R/Title(\(iv\) the current Executive Sponsor of the trauma program, if not 226 the CEO or CNO. 227 )>>endobj1272 0 obj<</Count 1/Dest[24 0 R/XYZ 36 138 null]/First 1273 0 R/Last 1273 0 R/Next 1140 0 R/Parent 1138 0 R/Prev 1274 0 R/SE 217 0 R/Title(\(iii\) current Trauma Medical Director 225 )>>endobj1273 0 obj<</Dest[24 0 R/XYZ 36 138 null]/Parent 1272 0 R/SE 218 0 R/Title(\(iii\) current Trauma Medical Director 225 )>>endobj1274 0 obj<</Count 1/Dest[24 0 R/XYZ 36 152 null]/First 1275 0 R/Last 1275 0 R/Next 1272 0 R/Parent 1138 0 R/Prev 1139 0 R/SE 215 0 R/Title(\(ii\) the Chief Nursing Officer 224 )>>endobj1275 0 obj<</Dest[24 0 R/XYZ 36 152 null]/Parent 1274 0 R/SE 216 0 R/Title(\(ii\) the Chief Nursing Officer 224 )>>endobj1276 0 obj<</Dest[24 0 R/XYZ 36 166 null]/Parent 1139 0 R/SE 214 0 R/Title(\(i\) the Chief Executive Officer 223 )>>endobj1277 0 obj<</Dest[46 0 R/XYZ 36 345 null]/Parent 919 0 R/SE 450 0 R/Title(\(A\) A radiologist shall be on-call and promptly available within 30 621 minutes of request from inside or outside the hospital. This system 622 shall be continuously monitored by the trauma PI program. 623 )>>endobj1278 0 obj<</Dest[48 0 R/XYZ 36 511 null]/Parent 898 0 R/SE 473 0 R/Title(\(i\) monitoring the clinical outcomes, direction and oversight of 655 the trauma program. 656 )>>endobj1279 0 obj<</Dest[64 0 R/XYZ 36 152 null]/Parent 746 0 R/SE 632 0 R/Title(\(A\) A defined individual to coordinate the facility•s community outreach 911 and education programs for the public and professionals is evident. 912 )>>endobj1280 0 obj<</Dest[64 0 R/XYZ 36 111 null]/Parent 743 0 R/SE 636 0 R/Title(\(B\) Provide education to and consultations with physicians of the 914 community and outlying areas; 915 )>>endobj1281 0 obj<</Dest[66 0 R/XYZ 36 704 null]/Parent 740 0 R/SE 641 0 R/Title(\(C\) Training programs in trauma continuing education provided by facility 917 for staff and community members involved in trauma care based on 918 needs identified from the QAPI program for: 919 )>>endobj1282 0 obj<</Dest[66 0 R/XYZ 36 552 null]/Parent 736 0 R/SE 656 0 R/Title(\(vi\) any other appropriate personnel involved in trauma care. 928 )>>endobj1283 0 obj<</Count 1/Dest[66 0 R/XYZ 36 566 null]/First 1284 0 R/Last 1284 0 R/Next 736 0 R/Parent 734 0 R/Prev 1285 0 R/SE 653 0 R/Title(\(v\) prehospital personnel; and 927 )>>endobj1284 0 obj<</Dest[66 0 R/XYZ 36 566 null]/Parent 1283 0 R/SE 654 0 R/Title(\(v\) prehospital personnel; and 927 )>>endobj1285 0 obj<</Count 1/Dest[66 0 R/XYZ 36 580 null]/First 1286 0 R/Last 1286 0 R/Next 1283 0 R/Parent 734 0 R/Prev 1287 0 R/SE 651 0 R/Title(\(iv\) specialty and community physicians; 926 )>>endobj1286 0 obj<</Dest[66 0 R/XYZ 36 580 null]/Parent 1285 0 R/SE 652 0 R/Title(\(iv\) specialty and community physicians; 926 )>>endobj1287 0 obj<</Count 1/Dest[66 0 R/XYZ 36 608 null]/First 1288 0 R/Last 1288 0 R/Next 1285 0 R/Parent 734 0 R/Prev 1289 0 R/SE 649 0 R/Title(\(iii\) allied health personnel including Physician Assistants and 924 Advanced Nurse Practitioners; 925 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